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AMERICAN  ILLUSTRATED 

MEDICAL  DICTIONARY 


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Surgery, 
her  with 
ns,  etc.; 
Diseases, 
f  Treat- 
imerican 
i  in   full 

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nts'  dic- 
er of  the 
e  leather, 
r.  for  con- 
>rds,  and 
nary.  It 
ndred  of 
Methods, 
many  of 


\  ithin  rela- 

Lerested  in 

:ll  Park, 

Professor  of  Principles  and  Practice  of  Surgery  and  LUnicaL  Surgery,  University  of  Buffalo. 

"  Dr.  Dorland's  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.  No  errors  have  been  found  in  my  use  of  it." — Howard  A.  Kelly,  Professor  of  Gyne- 
cology, fohns  Hopkins  University,  Baltimore. 

W.  B.  SAUNDERS  COMPANY,  925  Walnut  St.,  Phila. 
London:  9,  Henrietta  Street,  Covent  Garden 


Sixth  Edition,  Just  Issued  With  Complete  Vocabulary 

THE 

0 

AMERICAN  POCKET 

MEDICAL  DICTIONARY 

EDITED  BY 

W.  A.  NEWMAN   DORLAND,  A.M.,  M.  D., 

Assistant    Demonstrator  of   Obstetrics,   University   of    Pennsylvania. 

HUNDREDS  OF  NEw"  TERMS 

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The  book  is  an  absolutely  new  one.  It  is  not  a  revi- 
sion of  any  old  work,  but  it  has  been  written  entirely  anew 
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complete,  and  to  that  end  contains  practically  all  the  terms 
of  modern  medicine.  This  makes  an  unusually  large  vocabu- 
lary. Besides  the  ordinary  dictionary  terms  the  book  contains 
a  wealth  of  anatomical  and  other  tables.  This  matter  is 
of  particular  value  to  students  for  memorizing  in  preparation 
for  examination. 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  ex- 
terior. I  can  recommend  it  to  our  students  without  reserve." — James  W.  Hol- 
land, M.  D.,  of  Jefferson  Medical  College. 

**  This  is  a  handy  pocket  dictionary,  which  is  so  full  and  complete  that  it  puts 
to  shame  some  of  the  more  pretentious  volumes." — Journal  of  the  American 
Medical  Association. 

"  We  have  consulted  it  for  the  meaning  of  many  new  and  rare  terms,  and 
have  not  met  with  a  disappointment.  The  definitions  are  exquisitely  clear  and 
concise.  We  have  never  found  so  much  information  in  so  small  a  space." — 
Dublin  Journal  of  Medical  Science. 

"  This  is  a  handy  little  volume  that,  upon  examination,  seems  fairly  to  fulfil 
the  promise  of  its  title,  and  to  contain  a  vast  amount  of  information  in  a  very 
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W.  B.  SAUNDERS  COMPANY,  925  Walnut  St.,  Phila. 
London:  9,  Henrietta  Street,  Covent  Garden 


ESSENTIALS 


OF 


GYNECOLOGY. 


Since  the  issue  of  the  first  volume  of  the 
Saunders  Question=Compends, 

OVER  290,000  COPIES 

of  these  unrivalled  publications  have  been  sold. 
This  enormous  sale  is  indisputable  evidence 
of  the  value  of  these  self-helps  to  students 
and  physicians. 


Cx  •     'gJL* — . 


SAUNDERS'   QUESTION-COMPENDS._  No.  iO. 

ESSENTIALS  OF 

GYNECOLOGY 

ARRANGED    IN   THE   FORM   OF 

QUESTIONS  AND  ANSWERS 

PREPARED  ESPECIALLY   FOR  STUDENTS   OF  MEDICINE 

BY 

EDWIN   B*  CRAGIN,  M*D. 

Professor  of  Obstetrics  and   Gynecology,  College  of   Physicians  and  Surgeons,  New 
York;  Attending  Physician  to  the  Sloane  Maternity  Hospital;  Consulting  Gyne- 
cologist to  the  New  York  Infirmary  for  Women  and  Children  ;  Consulting 
Obstetric  Surgeon,  City  Maternity  Hospital,  the  Sydenham  Hospital, 
and  the  New  York  Infant  Asylum  ;   Consulting  Gynecologist 
and  Obstetrician  to  the  Lincoln  Hospital  and  Home 

SEVENTH  EDITION,    THOROUGHLY  REVISED 

BY 

FRANK  S.  MATHEWS,  M.D. 

Instructor  in  Gynecology,  College  of  Physicians  and  Surgeons,  New  York ;    Associate 
Surgeon,  St.  Mary's  Free  Hospital  for  Children;   Assistant  Surgeon  to  the 
General  Memorial  Hospital;  Attending  Gynecologist,  Roose- 
velt Hospital,  Out-Patient  Department 

WITH  59  ILLUSTRATIONS 

PHILADELPHIA   AND   LONDON 

W.  B,  SAUNDERS  COMPANY 

J909 


Set  up,  electrotyped,  printed,  and  copyrighted   February,  1890.     Reprinted  September, 
1890.     Revised,  reprinted,  and  recopyrighted  June,  1891.     Reprinted  November, 
1892.     Revised,  reprinted,  and  recopyrighted  February,  1894.     Reprinted 
June,  1895.     Revised,  reprinted,  and  recopyrighted   October,  1897. 
Reprinted  May,  1899.     Revised,  reprinted,  and  recopyrighted 
July,  1901.     Reprinted  May,  1903.      Revised,  reprinted, 
and    recopyrighted    August,     1905.       Reprinted 
June,    1906.     Revised,    reprinted,    and    re- 
copyrighted August,  1909 


Copyright,  1909,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 


PRESS    OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


PREFACE  TO  SEVENTH  EDITION 


The  frequent  editions  through  which  this  little  work 
has  passed  seem  to  indicate  that  it  occupies  a  useful 
niche  in  the  book-world,  and  therefore  justifies  an  at- 
tempt once  more  to  make  it  harmonize  with  present 
ideas  and  teaching. 

E.  B.  C. 

9 


PREFACE  TO  FIRST  EDITION. 


No  one  appreciates  more  fully  than  the  Author  the  inadequacy  of 
this  little  work  for  a  thorough  study  of  Gynaecology.  This  has  not 
been  the  aim.  He  only  hopes  that  as  a  means  of  review  and  as  a 
summary  of  the  results  of  more  extensive  reading,  the  student  may 
find  the  work  of  some  value.  The  Author  wishes  also  to  state  that 
in  its  compilation  he  has  freely  consulted,  and  made  use  of,  the 
standard  works  of  Hart  and  Barbour,  Thomas,  Schroeder,  The 
American  System  of  Gynaecology,  notes  on  the  lectures  of  Prof. 
Geo,  M„  Tuttle  at  the  College  of  Physicians  and  Surgeons,  New 
York,  and  numerous  journals. 

E.  B.  C. 


n 


CONTENTS 


PAGE 

Mons  Veneris 17 

Labia  Majora 17 

Labia  Minora IS 

Clitoris 18 

Vestibule 20 

Fourchette 20 

Fossa  Navicularis 20 

Bulbs  of  the  Vestibule 20 

Vulvo-vaginal  Glands , 21 

Hymen ■ 21 

Vagina 21 

Vaginal  Secretion 22 

Uterus 24 

Mucous  Membrane  of  Uterus 25 

Fallopian  Tubes 31 

Ovaries 33 

Parovarium , 35 

Urinary  Tract 35 

Bladder 36 

Kectum 38 

Pelvic  Floor 40 

Perineal  Body 41 

Muscles  of  the  Perineum 42 

Ischio-rectal  Fossa 42 

Development  of  Pelvic  Organs 43 

Physical  Examination  of  Pelvic  Organs 43 

Positions  for  Examinations 44 

Vaginal  Examination 45 

Bimanual  Examination , 46 

Rectal  Examination 48 

Instruments 49 

Specula 49 

The  Sims  Speculum 49 

13 


14  CONTENTS 

PAGE 

Instruments,  Specula,  the  Simons  Speculum 51 

The  Fergusson  Speculum 52 

The  Brewer  Speculum 53 

Cystoscopes - 54 

Volsella 55 

Uterine  Sound 56 

Uterine  Probe 60 

Uterine  Applicator 60 

Dilators 60 

Tents 60 

Graduated  Hard  Dilators 61 

Elastic  Dilators 63 

Stem  Pessaries  , 64 

The  Curette ♦   .    .  64 

Drugs  Acting  on  the  Pelvic  Organs 66 

Vulvitis i 68 

Acute  Simple  Catarrhal 68 

Chronic  Catarrhal 69 

Gonorrhoea  and  Gonorrhoea! 69 

Phlegmonous 72 

Croupous 74 

Gangrenous ...  74 

Follicular 74 

Cyst  and  Abscess  of  Vulvo-vaginal  Gland 75 

Pudendal  Hernia 77 

Pudendal  Hematocele 77 

Haemorrhage  from  Vulva ■ 79 

Skin  Diseases  of  the  Vulva 79 

Erythema  of  the  Vulva 79 

Eczema  of  the  Vulva 80 

Herpes  of  the  Vulva 81 

New  Growths  of  the  Vulva 81 

Simple  Papillomata 81 

Pointed  Condylomata 82 

Syphilitic  Condylomata 82 

Adherent  Prepuce 82 

Pruritus  Vulvae 83 

Kraurosis  Vulvae 84 

Hyperesthesia  of  the  Vulva 85 

Vaginismus 86 

Coccygodynia 86 

Irritable  Urethral  Caruncle 87 


CONTENTS  15 

PAGE 

Prolapse  of  Urethral  Mucous  Membrane 88 

Malformations  of  the  Vulva 89 

Diseases  of  the  Vagina .  89 

Bacteria  of  the  Vagina 89 

Simple  Catarrhal  Vaginitis • 90 

Gonorrheal  Vaginitis 91 

Ulcerative  Vaginitis 92 

Croupous  Vaginitis 93 

Pelvic  Peritoneum 93 

Pelvic  Peritonitis 94 

Pelvic  Cellulitis 97 

Pelvic  Hematocele  and  Hematoma 100 

Menstruation 104 

Disorders  of  Menstruation 105 

Amenorrhoea 105 

Vicarious  Menstruation 107 

Menorrhagia  and  Metrorrhagia 107 

Dysmenorrhcea 108 

Obstructive 109 

Congestive ,    .    .    .    .  110 

Neuralgic Ill 

Ovarian .  m 

Membranous .  HI 

Sterility 113 

Malformations  of  the  Vagina 115 

Atresia  of  the  Vagina 115 

Stenosis  of  the  Vagina „ 117 

Malformations  of  the  Uterus 117 

Displacements  of  the  Uterus 122 

Anteversion , 122 

Anteflexion 122 

Retroversion  and  Retroflexion 125 

Pessaries 130 

Alexander's  Operation 133 

Hysterorrhaphy 135 

Prolapsus  Uteri 137 

Laceration  of  the  Perineum  and  Relaxation  of  Vaginal  Outlet .    .  141 

Hegar's  Operation „    .    .  143 

Emmet's  Operation 144 

Saenger-Tait  Operation 146 

Warren's  Operation 150 

Noble's  Operation 150 


16  CONTENTS 

PAGE 

Laceration  of  the  Perineum  and  Relaxation  of   Vaginal  Outlet, 

Cragin's  Operation 151 

Anterior  Colporrhaphy 152 

Hypertrophy  of  the  Cervix 154 

Stenosis  of  the  Cervix „ 155 

Laceration  of  the  Cervix 156 

Trachelorrhaphy 160 

Endometritis 161 

Acute  .    . 161 

Chronic 163 

Metritis 170 

Acute  Metritis 170 

Chronic  Metritis 171 

Atrophy  of  the  Uterus 173 

Fibroid  Tumors  of  the  Uterus 174 

Inversion  of  the  Uterus 185 

Polypi '    .    .    .  190 

Carcinoma  Uteri 193 

Vaginal  Hysterectomy 197 

Sarcoma  of  the  Uterus 199 

Chorio-epithelioma 200 

Salpingitis 201 

Tubercular  Salpingitis 205 

Affections  of  the  Ovaries 206 

Haemorrhage  into  the  Ovaries 206 

Ovaritis 207 

Prolapse  of  the  Ovary 210 

Tumors  of  the  Ovary - 210 

Cysts  of  the  Ovary  .    .    . .  211 

Parovarian  Cysts 217 

Preparation  of  Catgut 220 

Ectopic  Gestation 221 

Fistula 'v.--" 226 

Recto-vaginal  Fistula . -•    .  228 

Index 229 


ESSENTIALS  OF  GYNECOLOGY. 


What  is  included  in  the  term  external  genitals  ? 

That  portion  of  the  genital  tract  which  is  visible  when  the  patient 
is  in  the  dorsal  position,  with  knees  elevated  and  the  labia  separated 
with  the  fingers,  viz.  :  Mons  Veneris,  Labia  Majora,  Labia  Minora, 
Clitoris,  Vestibule,  Fourchette  and  Fossa  Navicularis. 

What   other  terms  are   in  common  use   for  the  external 
genitals  ? 

Pudendum  and  Vulva. 

The  term  vulva  is  inexact,  as  it  originally  applied  to  the  labia, 
nevertheless  it  is  in  common  use. 

What  comprise  the  internal  organs  of  generation  ? 

The  Uterus,  Fallopian  tubes  and  Ovaries. 

The  Vagina  connects  the  external  with  the  internal  generative 
organs. 

Budin  regards  the  Hymen  as  anatomically  a  folding  in  of  the 
vaginal  walls. 

Mons  Veneris. 
Describe. 

The  Mons  Veneris  is  a  triangular  projection,  or  cushion  of  adipose 
tissue,  situated  over  the  symphysis  pubis.  Anatomically,  in  addition 
to  adipose  tissue,  it  contains  fibrous  and  elastic  tissue.  After 
puberty  it  is  covered  with  hair,  which  has  a  tendency  to  curl,  and 
is  usually  somewhat  darker  than  the  hair  of  the  head.  Numerous 
sebaceous  and  sweat  glands  are  present. 

Labia  Majora. 

Describe  them. 

The  labia  majora  are  two  folds  of  skin  which  extend  from  the 
mons  veneris  in  front  to  meet  in  the  fourchette  posteriorly ;  they 
2  17 


18  ESSENTIALS  OE  GYNECOLOGY. 

are  covered  externally  with  coarse  hair,  and  richly  supplied  with 
sebaceous  and  sweat  glands ;  they  also  contain  adipose,  fibrous  and 
elastic  tissue.  Above,  the  round  ligament  can  be  traced  into  them  on 
either  side  ;  also  the  remains  of  the  canal  of  Nuck,  which  sometimes 
continues  pervious  and  admits  of  hernia.  The  inner  surface  of  the 
labia  is  smooth,  and  somewhat  resembles  mucous  membrane,  a  few 
fine  hairs,  however,  are  visible  on  close  inspection. 

The  labia  majora  in  the  virgin  lie  in  contact ;  in  old  women  they 
become  atrophied  and  allow  the  labia  minora  to  protrude. 

The  arterial  supply  is  the  superficial  perineal  branch  of  the  internal 
pudic  and  the  superficial  external  pudic.  The  veins  communicate 
with  the  bulbs  of  the  vagina  and  take  the  course  of  the  arteries. 
The  lymphatics  empty  into  the  inguinal  glands.  The  nerve  supply 
is  from  the  superficial  perineal  branches  of  the  internal  pudic,  the 
ilio-inguinal,  and  the  genito-crural. 

Labia  Minora. 

Describe. 

The  labia  minora,  or  nyniphse,  are  two  folds  of  muco-cutaneous 
tissue  which  arise  about  the  middle  of  the  labia  majora  on  their 
inner  surfaces,  and  extending  upward  divide  into  two  portions ;  the 
two  lower  uniting  just  below  the  clitoris  to  form  the  fraenum,  the 
two  upper  just  above  the  clitoris  to  form  the  prepuce.  The  venous 
supply  is  rich ;  it  communicates  with  the  bulbs  of  the  vagina  and 
with  the  pudic  and  perineal  veins.  The  arterial  supply,  nerves  and 
lymphatics  are  the  same  as  for  the  labia  majora.  The  sebaceous 
glands  are  very  abundant. 

Clitoris. 

Describe. 

The  clitoris,  the  analogue  of  the  penis  in  the  male,  is  situated  at 
the  apex  of  the  vestibule ;  it  consists  of  a  glans,  a  body,  and  two  crura. 

The  glans,  the  only  part  visible,  is  a  mass  of  erectile  tissue,  about 
the  size  of  a  small  pea,  very  abundantly  supplied  with  nerves  and 
partially  covered  by  its  prepuce. 

The  body  also  consists  of  erectile  tissue ;  it  is  about  an  inch  long, 
surrounded  by  a  firm  fibrous  covering,  and  shown,  on  section,  to 
consist  of  two  halves,  corpora  cavernosa,  separated  by  an  imperfect 
septum. 


CLITORIS.  19 

The  crura  are  two  prolongations  of  erectile  tissue  with  a  dense 
fibrous  sheath ;  they  arise  from  the  anterior  borders  and  inner  sur- 
faces of  the  pubic  and  ischiatic  rami,  and  extend  forward  to  unite 
in  the  body  just  beneath  the  pubic  arch. 

Give  the  vascular  supply  of  the  clitoris. 

The  arterial  supply  is  from  the  two  terminal  branches  of  the  in- 
ternal pudic.  The  blood  is  returned  by  the  dorsal  vein  which  empties 
into  the  vesical  plexus. 

Describe  the  lymphatics  of  the  clitoris. 

The  clitoris  is  surrounded  by  a  plexus  of  lymphatics  which  termi- 
nate in  the  inguinal  glands. 

Describe  the  nerve  supply  of  the  clitoris. 

The  clitoris  receives  numerous  filaments  both  from  the  sympa- 
thetic system  and  from  the  pudic  nerve. 

According  to  Savage,  "small  as  this  organ  is  compared  with  the 
penis,  it  has  in  proportion  four  or  five  times  the  nervous  supply  of 
the  latter." 

What  are  the  differences  between  the  clitoris  and  the  penis  ? 

The  clitoris  has  neither  corpus  spongiosum  nor  urethra,  both  of 
which  are  present  in  the  penis. 

What  are  the  points  of  resemblance  between  the  clitoris  and 
the  penis  ? 

They  are  both  erectile. 

They  each  consist  of  a  glans,  a  body  and  two  crura. 

They  each  have  two  corpora  cavernosa  separated  by  an  incomplete 
septum.  The  glans  in  each  is  partly  covered  by  a  prepuce,  with 
its  frsenurn  attached  below. 

What  do  we  find  in  the  female  as  the  analogue  of  the  corpus 
spongiosum  in  the  male  ? 

The  bulbs  of  the  vestibule  and  the  labia  minora,  which,  in  the 
female,  lie  at  the  side  of  the  urethra,  correspond  to  the  corpus 
spongiosum  in  the  male. 

What  in  the  male  is  the  analogue  of  the  labia  major  a  in 
the  female? 
The  scrotum. 


20  ESSENTIALS   OF   GYNAECOLOGY. 

Vestibule. 
Describe. 

The  vestibule  is  the  remains  of  the  uro-genital  sinus.  It  is  the 
space  seen  on  separating  the  labia  minora.  In  front  of  it  lies  the 
clitoris,  behind  is  the  fourchette,  and  on  either  side  is  a  labium 
minus.  Some  authors  unwisely  restrict  the  term  which  should 
describe  a  space  to  the  triangular  surface  of  mucosa  anterior  to  the 
vagina  and  between  the  labia,  the  area  in  the  center  of  which  is  the 
urethral  orifice.  Beneath  its  mucous  membrane  lie  venous  plexuses, 
the  bulbs  of  the  vagina,  and  the  pars  intermedia.  The  vestibular 
mucosa  differs  from  the  labia  and  mons  veneris  in  having  no  seba- 
ceous glands.  The  urethra,  vagina,  and  ducts  of  Bartholin  open 
into  it. 

Fourchette. 

Describe. 

The  fourchette,  or  posterior  commissure,  is  a  mere  fold  of  skin 
formed  by  the  junction  of  the  labia  majora  at  the  anterior  edge  of 
the  perineum. 

Fossa  Navicularis. 

Describe. 

The  fossa  navicularis  is  a  boat-shaped  cavity  which  is  formed 
between  the  lower  portion  of  the  hymen  and  the  inner  aspect  of 
the  fourchette,  when  the  latter  is  pulled  down  with  the  finger,  or 
the  labia  are  separated. 

When  the  parts  are  at  rest,  no  such  hollow  exists. 

Bulbs  of  the  Vestibule. 

Describe  them. 

The  bulbs  of  the  vestibule  are  two  oval  masses  of  erectile  tissue 
situated  on  either  side  of  the  ostium  vaginae  and  base  of  the  vesti- 
bule ;  posteriorly,  they  lie  in  contact  with  the  anterior  layer  of  the 
triangular  ligament ;  they  are  partially  covered  in  front  by  the  bulbo- 
cavernosi  muscles  ;  they  extend  as  high  as  the  meatus  urinarius,  and 
are  connected  by  the  pars  intermedia  with  the  cavernous  tissue  of 
the  clitoris.  Their  size  varies  greatly  from  that  of  a  bean,  as  given 
by  Hart  and  Barbour,  to  a  mass  an  inch  and  a  half  long. 


VAGINA.  21 

Vulvo-Vaginal  Glands. 

Describe. 

The  vulvovaginal,  or  Bartholinian  glands  are  small  oval  bodies 
about  the  size  of  an  almond,  lying  just  behind  the  lower  extremities 
of  the  bulbs  ;  they  lie  between  the  layers  of  the  triangular  ligament, 
and  each  gland  has  a  duct  about  half  an  inch  in  length  which  opens 
just  in  front  of  the  hymen  on  each  side.  They  are  the  analogue 
of  Cowper's  glands  in  the  male. 

They  secrete  a  glairy  mucus  which  lubricates  the  parts. 

Hymen. 

Describe. 

The  hymen  is  a  fold  of  mucous  membrane  which  surrounds  the 
ostium  vaginae  ;  it  has  a  connective  tissue  framework,  and  contains 
blood-vessels  and  nerves,  and  has  a  squamous  epithelial  covering. 

From  its  histology  and  embryology,  it  is  a  fold  of  the  vaginal  wall. 

The  hymen  may  be  of  several  forms  ;  the  most  common  being  the 
crescentic.  Other  forms  are  the  annular,  making  a  ring  about  ihe 
ostium ;  the  cribriform,  perforated  by  numerous  small  holes ;  and 
the  fimbriated,  with  a  fringed  edge.  It  is  sometimes  imperforate, 
a  pathological  condition. 

What  value  has  the  hymen  as  a  criterion  of  chastity  ? 

Very  slight,  as  neither  is  its  absence  proof  that  intercourse  has 
taken  place,  nor  is  its  presence  an  absolute  proof  to  the  contrary. 

What  are  the  caruncuiae  myrtiformes  ? 

In  women  who  have  borne  children  there  are  found  papillary 
elevations  surrounding  the  vaginal  orifice.  These  are  the  remains 
of  the  hymen,  and  are  called  caruncuiae  myrtiformes 

Vagina. 
Describe. 

The  vagina  is  spoken  of  by  Hart  and  Barbour  as  "  a  mucous  slit  in 
the  pelvic  floor;"  it  is  the  canal  connecting  the  uterus  and  the 
vulva,  lying  between  the  bladder  and  urethra  in  front  and  the 
rectum  behind  ;  its  walls,  which  are  anterior  and  posterior,  are 
normally  in  contact. 


22  ESSENTIALS  OF  GYNECOLOGY. 

The  anterior  wall  measures  2-2J  inches  in  length,  the  posterior 
3-3J  inches.  The  anterior  wall  is  shorter  than  the  posterior,  from 
the  fact  that  the  uterus  is  set  into  the  anterior  wall. 

The  vagina  is  very  dilatable,  and  when  distended  is  conical  in 
shape,  being  much  more  roomy  above  than  below. 

The  vaginal  walls  on  section  are  seen  to  consist  of  three  layers : 
1,  mucous  ;  2,  muscular  ;  3,  connective  tissue. 

The  mucous  membrane  on  both  anterior  and  posterior  walls  presents 
at  the  lower  portion  of  the  canal  numerous  ridges  or  rugae,  extending 
transversely  from  a  central  column ;  the  anterior  being  the  more 
distinct.  The  epithelium  covering  the  mucous  membrane  is  of  the 
squamous  variety.  The  vaginal  mucous  membrane  normally  con- 
tains no  glands. 

The  muscular  coat  consists  of  two  layers  of  unstriped  muscle,  the 
outer  longitudinal  one  being  well  developed,  the  inner  circular  one 
being  poorly  developed  except  at  the  orifice. 

The  outer  coat  is  of  connective  tissue,  and  contains  the  external 
plexus  of  veins. 

The  roof,  or  fornix  of  the  vagina,  that  portion  of  the  canal  sur- 
rounding the  cervix,  is,  for  convenience,  divided  into  four  portions : 
the  anterior  fornix,  the  posterior  fornix,  and  the  lateral  fornices ; 
of  these  the  posterior  is  the  deepest. 

Describe  the  vaginal  secretion. 

It  is  a  rather  scant,  white,  opaque,  curdy  material,  made  up  of 
exfoliated  cells  of  the  vaginal  mucous  membrane,  a  few  leucocytes, 
and  some  exudate  from  the  blood-vessels.  It  contains  mucus  only 
from  admixture  with  the  cervical  secretion.  It  has  a  decided  acid 
reaction  due  to  lactic  acid,  resulting  from  the  action  of  the  many 
saprophytic  bacteria  normally  found  in  the  vagina. 

What  changes  may  occur  in  the  vaginal  reaction  ? 

It  becomes  alkaline  during  menstruation  and  for  a  short  pe- 
riod after  labor.  In  pathological  conditions  of  the  vagina,  such 
as  gonorrhoea,  it  is  alkaline.  During  pregnancy  the  acidity  is 
increased. 

What  follows  the  introduction  of  pathogenic  germs  into  the 
normal  vagina  ? 

Other  organisms  than  the  tubercle  bacillus  and  gonococcus  disap- 
pear within  a  few  days.  Their  destruction  is  due  to  the  acidity  of 
the  vagina,  its  anaerobic  condition,  and,  what  is  of  more  importance, 


VAGINA.  23 

the  bactericidal  power  of  the  serum  of  the  vaginal  secretion.  The 
absence  of  crypts,  glands,  and  hair-follicles,  as  well  as  its  being  less 
subjected  to  trauma  than  the  vulva,  explain  the  less  susceptibility  of 
the  vagina  to  gonorrhoeal,  chancroidal,  and  other  infections. 

What  is  the  arterial  supply  of  the  vagina  ? 

The  arterial  supply  is  from  the  vaginal  arteries,  which  supply  the 
lateral  walls  ;  branches  of  the  uterine  arteries  supplying  the  upper 
portion,  and  branches  of  the  pudendal  arteries  the  lower.  These 
anastomose  with  each  other  and  with  the  vesical  and  rectal 
arteries. 

Describe  the  veins  of  the  vagina. 

The  vaginal  veins  form  plexuses  which  surround  the  canal  like 
sheaths ;  one  being  external  to  the  muscular  layer,  the  other  just 
beneath  the  mucous  membrane. 

"These  communicate  freely  with  the  pudendal,  vesical  and  hemor- 
rhoidal plexuses  below,  and  with  the  plexuses  of  the  broad  ligament 
above."     These  veins  contain  no  valves. 

Describe  the  lymphatics  of  the  vagina. 

The  lymphatics  of  the  lower  fourth  of  the  vagina,  together  with 
those  from  the  external  genitals  enter  the  inguinal  glands. 

The  lymphatics  from  the  upper  three-fourths  of  the  vagina  join 
with  those  from  the  cervix  and  bladder,  and  enter  the  iliac  glands. 

According  to  Poirier,  some  of  them  enter  a  gland  at  the  side  of 
the  cervix  in  the  base  of  the  broad  ligament. 

Describe  the  nerve  supply  of  the  vagina. 

The  vagina  is  supplied  by  branches  of  the  inferior  hypogastric 
plexuses  of  the  sympathetic  system.  These  plexuses  lie  on  either 
side  of  the  vagina. 

Give  the  relations  of  the  vagina. 

The  anterior  vaginal  wall  is  connected  in  its  lower  half  with  the 
urethra,  in  its  upper  half  with  the  neck  and  fundus  of  the  bladder ; 
the  former  connection  is  much  more  intimate  than  the  latter.  The 
posterior  vaginal  wall  in  its  lower  fourth  lies  in  connection  with  the 
perineal  body,  in  its  middle  two-fourths  with  the  rectum,  in  its  upper 
fourth  with  the  cul-de-sac  of  Douglas.  The  anterior  fornix  is  distant 
l£  inches  from  the  utero-vesical  pouch,  and  through  this  fornix  can 
normally  be  felt  the  body  of  the  uterus  and  the  angle  it  makes  with 
the  cervix. 


24 


ESSENTIALS   OF   GYNAECOLOGY. 


Fig.  1. 


The  posterior  fornix  is  in  contact  with  the  cul-de-sac  of  Douglas. 
The  lateral  fornices  are  in  relation  with  the  bases  of  the  "broad  liga- 
ments, and  through  these  fornices  can  normally  be  felt  the  vessels  of 
the  broad  ligament,  and  occasionally  the  ovary  and  tube  of  that  side. 

The  vagina  makes  an  angle  of  60°  with  the  horizon  when  the 
woman  is  erect. 

Uterus. 

Give  the  gross  anatomy. 

The  uterus,  the  organ  of  gestation,  is  a  hollow,  pear-shaped  organ, 
flattened  antero-posteriorly,  situated  in  the  pelvis  between  the  bladder 

and  rectum.  It  measures  in  the  virgin 
about  3  inches  in  length,  2  inches  in 
breadth,  at  the  level  of  the  Fallopian 
tubes,  and  1  inch  in  thickness.  The 
weight  of  the  virgin  uterus  varies  from 
1  to  1  g-  oz. 

It  consists  of  three  portions:  the 
cervix,  body  and  fundus. 

As  viewed  externally,  the  uterus,  on 
its  anterior  surface,  is  nearly  flat,  its 
posterior  surface  convex ;  a  little  below 
the  centre  is  a  slight  constriction  called 
the  isthmus. 

The  cervix  is  that  portion  of  the 
uterus  below  the  isthmus,  and  which 
projects  in  part  into  the  vagina. 

The  body  is  that  portion  between  the 
isthmus  and  the  line  joining  the  en- 
trance of  the  Fallopian  tubes. 
The  fundus  is  the  portion  above  this  line. 


Diagram  of  Uterus,  to  show  di- 
visions of  Cervix.  (Schroeder.) 

a,  Infra-vaginal  portion;  b,  In 
termediate  portion  ;  c,  Supra- 
vaginal portion ;  Bl,  Bladder ; 
P,  Peritoneum.  The  dotted 
line  shows  peritoneum. 


Describe  the  uterine  canal. 

The  uterine  canal  measures  normally  in  nulliparous  women  2 h  inches, 
and  holds  about  12  drops  ;  the  cervical  portion  of  the  canal  is  spindle- 
shaped  and  measures  at  least  1  inch  in  length ;  the  remainder  is 
triangular,  with  anterior  and  posterior  walls  in  contact. 

What  are  the  openings  into  the  uterine  cavity? 
There  are  three :  the  os  externum,  which  communicates  with  the 


MUCOUS   MEMBRANE   OP   THE   UTERUS.  25 

vagina ;  and  the  orifices  of  the  Fallopian  tubes  at  the  upper  angles, 
which  connect  the  uterine  with  the  peritoneal  cavity.  The  os 
internum  connects  the  cavity  of  the  cervix  with  that  of  the  body. 

What  divisions  of  the  cervix  are  made  ? 

Schroeder  divides  the  cervix  into  three  portions,  as  seen  from  the 
accompanying  figure,  (Fig.  1,  a,  b,  c). 

a.  The  infra-vaginal  portion. 

b.  The  intermediate  portion. 

c.  The  supra-vaginal  portion. 

The  infra-vaginal  portion  of  the  cervix  (a)  is  that  below  the  level 
of  the  attachment  of  the  anterior  vaginal  wall. 

The  supra-vaginal  portion  (c)  is  that  above  the  level  of  the  attach- 
ment of  the  posterior  vaginal  wall. 

The  intermediate  portion  (6)  is  that  between  the  infra-  and  supra- 
vaginal portions. 

What  portions  of  the  cervix  project  into  the  vagina  ? 

The  infra-vaginal  portion  of  the  anterior  lip,  and  the  infra-vaginal 
and  intermediate  portions  of  the  posterior  lip. 

For  practical  purposes,  it  is  sufficient  to  divide  the  cervix  into  the 
supra-vaginal  portion,  that  above  the  attachment  of  the  vagina ; 
and  the  infra-vaginal,  that  within  the  vagina. 

What  are  the  three  elements  in  the  structure  of  the  uterus  ? 

1.  The  mucous  membrane. 

2.  The  muscular  coat. 

3.  The  peritoneal  coat. 

Mucous  Membrane  of  the  Uterus. 

Describe  that  of  the  cervix. 

The  mucous  lining  of  the  cervix  differs  from  that  of  the  body  of 
the  uterus.  In  the  cervix  it  is  thrown  into  folds  presenting  the 
arbor  vitse  appearance,  there  being  a  central  ridge  on  both  anterior 
and  posterior  walls,  and  from  these  ridges  secondary  ridges  extend- 
ing obliquely. 

The  anterior  and  posterior  ridges  are  not  directly  opposite,  but  fit 
past  one  another.  The  epithelium  is  ciliated  on  the  ridges,  non- 
ciliated  in  the  depressions,  according  to  some  writers ;  others  have 
failed  entirely  to  demonstrate  cilia;  in  the  cervix . 


26  ESSENTIALS   OF  GYNAECOLOGY. 

The  mucous  membrane  of  the  cervix  is  rather  sparingly  supplied 
with  acinus  glands  whose  secretion  is  mucous. 

The  mucous  membrane  covering  the  vaginal  portion  of  the  cervix 
closely  resembles  that  of  the  vagina,  consisting  of  vascular  papillae 
covered  by  squamous  epithelium. 

Describe  the  mucous  membrane  of  the  body  of  the  uterus. 

The  mucous  lining  of  the  body  of  the  uterus  is  smooth,  velvety 
and  of  a  grayish  red  color  ;  it  is  directly  connected  with  the  muscu- 
lar coat,  with  no  submucous  layer.  It  averages  about  >}5  of  an  inch 
in  thickness,  and  consists  of  columnar,  ciliated  epithelium,  on  a  base 
of  connective  tissue  between  whose  fibres  numerous  lymph  spaces 
are  found.  The  mucous  membrane  is  thickly  studded  with  glands, 
the  utricular  glands,  which  penetrate  the  whole  thickness  of  the 
mucous  layer.  These  glands  are  of  the  tubular  variety,  and  are  fre- 
quently bifurcated  at  their  blind  extremities.  They  are  lined  with 
cylindrical  epithelium,  resting  on  a  thin  membrana  propria.  Their 
direction  is  not  at  right  angles  to  the  surface,  but,  according  to 
Turner,  more  or  less  oblique.  Their  secretion  is  less  thick  and 
tenacious  than  that  of  the  cervix. 

To  what  changes  is  the  normal  uterine  mucosa  subject? 

1.  That  of  the  child  is  destitute  of  glands.  These  make  their 
appearance  a  few  years  before  puberty. 

2.  Preceding  each  menstrual  flow  the  cells  of  the  stroma  become 
swollen,  the  superficial  capillaries  dilated,  and  finally  there  is  an  exu- 
dation of  plasma  and  diapedesis  of  red  cells  under  the  epithelium. 
There  is  no  extensive  shedding  of  mucosa  with  the  menstrual  flow, 
as  was  formerly  thought,  except  in  the  condition  known  as  mem- 
branous dysmenorrhea. 

3.  Should  pregnancy  occur,  the  stroma  cells  become  much  larger 
and  polygonal,  glands  disappear  from  the  surface  of  the  mucosa,  and 
are  only  seen  as  distorted  and  cystic  ones  in  the  deep  layer.  Thus 
altered  the  mucosa  becomes  the  "decidua." 

4.  After  the  menopause  the  mucosa  atrophies  and  nearly  all 
glands  disappear. 

Describe  the  muscular  structure  of  the  uterus. 

The  muscular  structure  of  the  uterus  is  most  marked  after  im- 
pregnation ;  it  can  then  be  separated  into  three  layers  : — 


MUCOUS  MEMBRANE  OP  THE  UTERUS.  27 

1 .  The  external  or  longitudinal. 

2.  The  middle  or  oblique. 

3.  The  internal  or  circular. 

The  external  layer  is  most  distinct  on  the  anterior  and  posterior 
surfaces,  where  it  is  seen  to  consist  of  fibres  running  up  longitudi- 
nally over  the  fundus  ;  it  sends  fibres  into  the  broad,  round,  ovarian 
and  utero-sacral  ligaments  and  also  into  the  Fallopian  tubes. 

The  middle,  or  oblique  layer  has  no  regular  arrangement ;  some  of 
the  fibres  run  longitudinally,  some  transversely  and  some  obliquely ; 
they  surround  the  blood  vessels,  and  on  this  account  this  layer  is  of 
great  importance  ;  it  constitutes  the  chief  portion  of  the  uterine  wall. 

The  internal  or  circular  layer  shows  fibres  arranged  in  a  circular 
manner,  most  distinct  around  the  orifices  of  the  Fallopian  tubes  and 
at  the  os  internum. 

Describe  the  peritoneal  coat  of  the  uterus. 

The  peritoneum  covers  the  anterior  surface  of  the  uterus  above 
the  level  of  the  internal  os  ;  it  extends  over  the  fundus,  covers  its 
posterior  surface  as  low  as  the  attachment  of  the  posterior  vaginal 
wall,  and  extends  down  the  latter  for  about  an  inch. 

Describe  the  arterial  supply  of  the  uterus. 

The  uterus  is  supplied  by  the  uterine  and  ovarian  arteries,  as  seen 
by  the  accompanying  figure.     (Fig.  2. ) 

The  uterine  artery  arises  from  the  anterior  division  of  the  internal 
iliac,  runs  between  the  folds  of  the  broad  ligament  to  about  the 
level  of  the  os  externum,  and  then  turns  upward  along  the  side  of 
the  uterus  to  unite  with  the  descending  branch  of  the  ovarian  artery  ; 
it  gives  off  numerous  lateral  branches  to  the  uterus,  anastomosing 
with  those  of  the  opposite  side ;  these  are  very  tortuous  and  are 
called  the  ' '  curling  arteries  of  the  uterus. ' ' 

Sometimes  the  vaginal  artery  springs  directly  from  the  uterine. 

Opposite  the  internal  os,  the  uterine  artery  gives  off  a  branch 
which,  uniting  with  its  fellow  of  the  opposite  side,  surrounds  the 
cervix  and  is  called  "the  circular  artery." 

The  ovarian  artery  arises  directly  from  the  aorta,  enters  the  pelvis 
in  the  in fundibulo- pelvic  ligament,  runs  between  the  folds  of  the 
broad  ligament,  at  its  upper  part,  to  the  upper  angle  of  the  uterus  ; 
it  gives  off  a  few  large  vessels  to  the  outer  extremity  of  the  tube,  and 
then  a  number  of  very  tortuous  vessels  which  surround  the  ovary. 


28 


ESSENTIALS  OF  GYNECOLOGY. 


Just  before  reaching  the  uterus,  it  gives  off  a  number  of  branches 
to  the  proximal  extremity  of  the  tube  and  one  to  the  round  ligament. 

At  the  angle  of  the  uterus  it  divides  into  two  branches :  one  sup- 
plies the  fundus  and  anastomoses  with  its  fellow  of  the   opposite 

Fig.  2. 


Distribution  of  ovarian,  uterine  and  vaginal  arteries  (Hyrtt). 
a,  ovarian  artery;  a'  and  b\  branches  to  tube  ;  c',  branches  to  ovary  ;  b,  branch  to 
round  ligament;  c,  branch  to  fundus;  d,  branch  to  join  uterine  artery  ;  e,  uterine 
artery ;  /,  anterior  branch  of  internal  iliac ;  g,  vaginal  arteries  ;  h,  azygos  artery 
of  vagina. 


MUCOUS  MEMBRANE  OP  THE  UTERUS.  29 

side;  the  other  descends  along  the  side  of  the  uterus  and  anasto- 
moses with  the  uterine  artery. 

The  tortuosity  and  free  anastomoses  across  the  median  line  are 
noticeable  features  of  the  arteries  of  the  uterus. 

Describe  the  venous  supply  of  the  uterus. 

The  uterus  is  surrounded  beneath  the  peritoneum  by  a  plexus  of 
veins,  called  the  uterine  plexus  ;  this  receives  the  blood  from  the 
uterine  walls  and  communicates  with  the  vaginal  and  vesical  plexuses 
below  and  the  pampiniform  above ;  it  empties  into  the  internal  iliac 
and  ovarian  veins. 

Describe  the  lymphatics  of  the  uterus. 

The  lymphatics  from  the  body  of  the  uterus  join  with  those  from 
the  ovary  and  tube  and  terminate  in  the  lumbar  glands. 

The  lymphatics  from  the  cervix  pass  beneath  the  base  of  the 
broad  ligaments  to  the  iliac  glands. 

The  lymphatics  of  the  uterine  cornu  follow  the  round  ligament 
and  terminate  in  the  inguinal  glands. 

Give  the  nerve  supply  of  the  uterus. 

The  chief  nerve  supply  of  the  uterus  is  from  the  inferior  hypo- 
gastric plexus  of  the  sympathetic. 

The  cervix  also  receives  branches  from  the  upper  sacral  nerves. 

What  is  the  normal  position  of  the  uterus  ? 

This  question  has  been  frequently  discussed  and  at  great  length. 
It  is  now  sufficient  for  practical  purposes  to  say  that  the  uterus, 
when  the  pelvic  organs  are  normal  and  when  bladder  and  rectum  are 
empty,  lies  slightly  anteflexed  and  slightly  anteverted.  This  brings 
the  long,  axis  of  the  uterine  body  when  the  woman  is  standing  erect 
about  into  the  plane  of  the  horizon. 

Distention  of  bladder  and  rectum,  especially  the  former,  and 
the  pregnant  state  make  the  axis  shift  more  toward  the  ver. 
tical.  Since  the  uterus  is  not  a  fixed  but  a  movable  organ,  the 
remark  of  Waldeyer  seems  apropo  :  ' '  The  uterus  has  one  typical, 
but  many  normal,  positions." 

What  are  the  ligaments  of  the  uterus  ? 

There  are  two  utero- vesical  ligaments,  two  round,  two  broad,  and 
two  utero-sacral. 


30  ESSENTIALS   OF   GYNECOLOGY. 

Describe  the  utero-vesical  ligaments. 

They  are  two  folds  of  peritoneum  passing  between  the  bladder 
and  the  lower  portion  of  the  uterus  on  each  side. 

Describe  the  round  ligaments. 

They  are  two  musculo-fibrous  cords,  4-5  inches  in  length,  which 
extend  from  the  superior  angles  of  the  uterus,  in  the  anterior  folds 
of  the  broad  ligaments  and  below  the  Fallopian  tubes,  forward  and 
outward  to  the  inguinal  canal ;  thence  through  this  canal  where  they 
terminate  in  three  points  of  insertion  :  the  external,  middle  and 
internal.  The  external  blends  with  the  outer  pillar  of  the  ring  near 
Gimbernat's  ligament.  The  middle  terminates  in  the  upper  portion 
of  the  external  ring.  The  internal  unites  with  the  conjoined  tendon. 
Besides  muscular  and  fibrous  tissue,  these  ligaments  contain  areolar 
tissue,  vessels  and  nerves. 

They  are  of  importance  surgically  as  being  those  shortened  in 
operations  for  the  correction  of  posterior  displacements. 

Describe  the  broad  ligaments. 

They  are  two  folds  of  peritoneum  which  extend  from  the  sides  of 
the  uterus  to  the  wall  of  the  pelvis,  ' '  along  a  line  which  is  situ- 
ated between  the  great  sacro-sciatic  notch  and  the  margin  of  the 
obturator  foramen  as  far  down  as  the  level  of  the  ischial  spine. ' ' 
The  greater  part  of  its  superior  border,  on  each  side,  is  occupied  by 
the  Fallopian  tube  ;  the  part  of  the  superior  border  not  so  occupied 
is  called  the  infundibulo-pelvic  ligament. 

What  is  the  "  mesosalpinx  "  ? 

It  is  that  portion  of  the  broad  ligament  lying  between  the  tube, 
ovary,  and  ovarian  ligament.  It  contains  the  parovarian  tubules 
between  its  folds. 

What  two  folds  are  made  in  the  broad  ligament  in  addition 
to  that  occupied  by  the  Fallopian  tube  ? 

An  anterior  fold  caused  by  the  round  ligament  and  a  posterior  fold 
caused  by  the  ovarian  ligament. 

Describe  the  ovarian  ligament. 

It  is  a  fibro-muscular  cord  about  an  inch  in  length,  which  connects 
the  ovary  with  the  side  of  the  uterus,  just  below  the  entrance  of  the 
Fallopian  tube.  It  lies  in,  and  is  surrounded  by,  the  posterior  fold 
of  the  broad  ligament. 


FALLOPIAN  TUBES.  31 

What  are  contained  between  the  folds  of  the  broad  ligament 
on  either  side  ? 

The  round  ligament,  Fallopian  tube,  ovarian  ligament,  the  paro- 
varium, cellular  tissue,  uterine  and  ovarian  arteries,  the  pampiniform 
plexus  and  other  veins,  numerous  lymphatics  and  nerves. 

When  the  broad  ligament  is  held  tense  the  ovary  appears  as  if 
stuck  on  its  posterior  surface. 

Describe  the  utero-sacral  ligaments. 

These  ligaments  are  composed  of  muscular  and  fibrous  tissue  and 
are  covered  with  peritoneum.  In  front  they  blend  with  the  sides 
of  the  cervix  and  lower  uterine  segment.  They  pass  backward  and 
outward  on  either  side  of  the  rectum  to  become  lost  in  the  connec- 
tive tissue  on  the  front  of  the  sacrum  from  the  third  sacral  vertebra 
downward. 

What  is  the  action  of  the  uterine  ligaments  ? 

These  ligaments  come  into  play  only  when  the  uterus  by  strain- 
ing or  otherwise  is  considerably  displaced  from  its  typical  position. 
They  limit  the  normal  excursion  of  the  uterus.  Their  greatest  tax 
comes  during  labor,  when  they  fix  the  cervix,  and  by  so  doing  allow 
the  uterine  contractions  to  drive  the  uterine  contents  against  the 
pelvic  floor.  They  involute  with  the  uterus  during  the  puerperium. 
The  amount  of  force  which  they  must  resist  during  labor  attests 
their  strength.  One  realizes  their  strength  when  he  grasps  with 
volsella  the  cervix  and  pulls  against  them  in  the  course  of  vaginal 
hysterectomy. 

What  is  the  meaning  of  the  term  "uterine  appendages,"  as 
usually  employed  ? 

The  Fallopian  tubes  and  ovaries. 

Fallopian  Tubes. 

Describe  them. 

They  are  two  tubes  3-5  inches  in  length,  which  extend  laterally 
from  the  superior  angles  of  the  uterus  ;  they  lie  within  the  folds  of 
the  broad  ligaments,  and  their  direction  is  first  outward,  then  for- 
ward, backward  and  inward  toward  the  ovary. 

They  are  divided  for  consideration  into  three  portions  :  the  isth- 
mus, the  ampulla  and  the  fimbriated  extremity. 


32  ESSENTIALS   OE  GYNECOLOGY. 

The  isthmus  is  the  narrowest  portion ;  it  measures  about  an  inch 
in  length,  and  extends  from  the  angle  of  the  uterus  directly  outward, 
joining  the  ampulla  ;  its  lumen  is  only  large  enough  to  admit  a  fine 
bristle. 

The  ampulla  is  the  curved,  dilated  portion  of  the  tube  ;  its  lumen 
admitting  an  ordinary  uterine  sound. 

The  fimbriated  extremity  (infundibulum)  is  the  expanded,  funnel- 
shaped  outer  end,  which  is  surrounded  by  fringe-like  processes  (fim- 
briae), both  primary  and  secondaiy,  the  latter  arising  from  the 
former,  which  are  4-5  in  number.  The  longest  of  the  primary 
fimbriae  lies  to  the  inner  side,  is  grooved,  and  is  attached  to  the 
ovary  ;  this  is  called  the  fimbria  ovarica. 

The  tubes,  on  section,  are  seen  to  consist  of  four  layers  or  coats ; 
the  peritoneal  coat ;  two  muscular  coats,  the  outer  being  longitudinal, 
the  inner  circular ;  and  a  mucous  coat. 

There  is  no"  submucous  layer. 

The  mucous  membrane  is  thrown  into  longitudinal  folds  ;  the  epi- 
thelium is  columnar  and  ciliated. 

Give  the  arterial  supply  of  the  Fallopian  tubes. 

The  Fallopian  tubes  are  supplied  by  the  ovarian  arteries,  which 
send  branches  directly  to  the  outer  and  inner  portions  of  the  tube 
and  supply  the  middle  third  through  branches  from  the  plexus 
about  the  ovary. 

Describe  the  veins,  lymphatics  and  nerve  supply  of  the  Fal- 
lopian tubes. 

The  veins  of  the  tubes  enter  the  pampiniform  plexus  on  either 
side. 

The  lymphatics  join  with  those  from  the  upper  part  of  the  uterus 
and  frorn  the  ovaiy,  and  terminate  in  the  lumbar  glands. 

The  nerve  supply  is  from  the  inferior  hypogastric  plexuses. 

What  is  the  direction  of  the  current  due  to  motion  of  the  ciliae 
of  the  epithelium  in  the  uterus  and  tubes  ? 
The  ciliae  have  such  a  motion  as  to  propel  fluids  outward,  i.  e.,  in 
the  tube  toward  the  uterus,  and  in  the  uterus  toward  the  vagina. 


OVARIES.  3d 

Ovaries. 

Give  their  gross  anatomy. 

The  ovaries  are  two  "  flattened  ovoid  "  bodies  lying  in  the  plane 
of  the  brim  of  the  pelvis,  on  either  side  of  the  uterus,  and  appear 
as  elevations  on  the  posterior  surface  of  the  broad  ligament'.  They 
are  situated  below  the  outer  extremities  of  the  tubes. 

They  present  for  consideration  two  borders,  an  anterior  and  pos- 
terior ;  two  surfaces,  a  superior  and  an  inferior  ;  and  two  extremi- 
ties, an  outer  and  an  inner. 

The  anterior  border  is  nearly  straight ;  the  posterior  is  convex. 

The  anterior  border  is  called  the  hilum,  and  serves  for  the  en- 
trance of  blood  vessels  and  nerves. 

The  superior  surface  is  nearly  flat ;  the  inferior  is  convex. 

The  outer  extremity  is  broad  and  convex  ;  the  inner  is  narrow  and 
tapers  into  the  ovarian  ligament. 

An  ovary  averages  about  1}  inches  in  length,  f  of  an  inch  in 
breadth  and  j  an  inch  in  thickness;  it  weighs  about  87  grains. 

Give  the  minute  anatomy  of  the  ovary. 

The  ovary,  on  section,  is  seen  to  consist  of  a  medullary  and  cor- 
tical portion ;  the  former  being  more  vascular  and  of  a  softer  con- 
sistency than  the  latter.  The  microscope  shows  connective  tissue, 
numerous  Graafian  follicles  scattered  through  the  cortex,  blood  ves- 
sels, lymphatics,  nerves  and  unstriped  muscular  fibres. 

At  the  base  or  attachment  of  the  ovary  to  the  broad  ligament  can 
be  seen  a  white  line  which  marks  the  transition  from  the  flat  cells 
of  peritoneum  to  the  cuboidal  ones,  the  "germinal  epithelium'' 
covering  the  surface  of  the  ovary.  The  origin  of  both  sorts  of  cells 
is  the  same.  Both  are  derived  from  the  mesothelial  cells  of  the 
mesoblast,  and  later  become  differently  modified  to  fit  them  to  fulfil 
their  very  dissimilar  functions. 

The  layer  of  "germinal  epithelium  "  rests  on  a  thin,  dense  mus- 
culo-fibrous  layer,  called  the  tunica  albuginea. 

The  Graafian  follicles  are  small  vesicular  bodies,  more  numerous 
and  smaller  in  the  superficial  zone  of  the  cortex  than  in  the  deeper, 
with  the  exception  of  a  few  which  have  matured  and  approached 
the  surface  of  the  ovary. 

Foulis  estimates  that  at  birth  each  human  ovary  contains  not  less 
than  30,000  Graafian  follicles  (Playfair). 
3 


34 


ESSENTIALS   OF  GYNECOLOGY. 


Give  the  structure  of  a  Graafian  follicle. 

On  examining  a  Graafian  follicle  from  without  inward,  we  find 
the  following  structures  (Fig.  3) : — 

The  theca  folliculi,  which  is  divisible  into  an  outer  fibrous  layer, 
the  tunica  fibrosa,  and  an  inner  vascular  and  cellular  layer,  the 
tunica  propria ;  within  this  is  the  membrana  granulosa,  a  layer  of 
columnar  epithelium  which  encloses  the  liquor  foil iculi ;  at  one  side 
there  is  a  cellular  eminence  called  the  discus  proligerus,  which 
encloses  the  ovum.  The  outer  covering  of  the  ovum  is  the  vitelline 
membrane,  or  zona  pellucida,  surrounding  the  vitellus  or  yolk.  At 
one  point  of  the  latter  is  seen  the  germinal  vesicle,  and  within  this 
the  germinal  spot.  A  Graafian  follicle  measures  from  xio  to  2V 
inch  in  diameter ;  a  germinal  spot,  not  over  3^00  inch. 

Give  the  arterial  and  venous  supply  of  the  ovaries. 

The  ovaries  are  supplied  by  the  ovarian  arteries,  which  arise 
directly  from  the  aorta. 

The  veins  of  the  ovary  emerge  at  the  hilum  and  enter  the  collec- 
tion of  veins  called  the  "  bulb  of  the  ovary."  This  communicates 
with  the  veins  from  the  Fallopian  tube  and  upper  portion  of  the 


Diagrammatic  Section  of  Graafian  Follicle. 
1.  Ovum.     2.  Membrana  granulosa.     3.    External  membrane  of  Graafian  follicle. 
4.  Its  vessels.    5.  Ovarian  stroma.    6.   Cavity  of  Graafian  follicle.    7.  External 
covering  of  ovary. 

uterus,  forming  a  collection  called  the  pampiniform  or  ovarian 
plexus  ;  from  this  springs  the  ovarian  vein,  which,  on  the  right  side, 
terminates  in  the  inferior  vena  cava,  on  the  left  side,  in  the  left 


URINARY  TRACT.  35 

renal  vein.  The  left  ovarian  vein  has  no  valve  at  its  termination. 
Some  apply  the  term  pampiniform  plexus  to  all  the  veins  in  the 
broad  ligament. 

Give  the  lymphatics  and  nerve  supply  of  the  ovary. 

The  lymphatics  join  with  those  from  the  tube  and  upper  portion 
of  the  uterus  and  terminate  in  the  lumbar  glands.  The  nerve  sup- 
ply is  from  the  inferior  hypogastric  plexus. 

What  is  the  position  of  the  long  axis  of  the  ovary  ? 

This  question  has  been  much  discussed.  The  long  axis  of  the 
ovary  may  be  regarded  as  lying  a  little  obliquely  to  the  transverse 
axis  of  the  pelvis,  and  with  a  direction  slightly  backward.  His 
describes  the  long  axis  as  vertical,  but  this  does  not  coincide  with 
the  results  of  autopsies  where  the  pelvic  contents  have  been  normal. 

Parovarium. 

Describe  it. 

The  parovarium,  which  is  the  remains  of  the  Wolffian  body,  con- 
sists of  a  series  of  tubes  situated  between  the  folds  of  the  broad 
ligament,  on  either  side  of  the  uterus,  and  lying  between  the  am- 
pulla of  the  tube  and  the  hiluni  of  the  ovary. 

One  of  the  tubes  is  horizontal  and  runs  toward  the  uterus  ;  the 
others  are  nearly  vertical,  converging  toward  the  hiluni ;  they  vary 
greatly  in  number,  in  fact,  from  6  to  30. 

The  outer  6-10  have  a  well-marked  lumen  and  are  lined  with 
ciliated  epithelium ;  those  internal  to  these  are  merely  fine  fibrous 
cords. 

The  horizontal  tube  running  toward  the  uterus  is  called  the  duct 
of  Gartner.  It  is  rarely  continued  down  along  the  side  of  the  uterus 
or  even  to  the  vagina.  The  parovarium  is  of  pathological  importance, 
as  occasionally  the  seat  of  cysts. 

What  in  the  male  corresponds  to  the  parovarium  in  the 
female  ? 

The  epididymis. 

Urinary  Tract. 
Describe  the  urethra. 

The  female  urethra  is  a  musculo-membranous  canal  about  If 
inches  in  length,  imbedded  in  the  anterior  vaginal  wall,  and  extend- 


36  ESSENTIALS   OF   GYNAECOLOGY. 

ing  from  the  vestibule  to  the  neck  of  the  bladder ;  it  runs  upward 
and  backward,  "  parallel  with  the  plane  of  the  pelvic  brim." 

It  consists  of  three  coats;  the  outer  two  being  muscular,  the 
inner,  mucous  membrane. 

Of  the  muscular  coats,  the  outer  is  circular,  the  inner  longitudi- 
nal. The  mucous  membrane  in  the  lower  portion  of  the  canal  is 
covered  with  squamous  epithelium,  while  higher  up  the  epithelium 
is  transitional,  like  that  of  the  bladder. 

The  meatus  urinarius,  the  outer  extremity  of  the  urethra,  is  situ- 
ated in  the  median  line  of  the  vestibule,  lying  a  short  distance  in 
front  of  the  vaginal  orifice. 

Describe  Skene's  tubules. 

Just  within  the  meatus,  on  each  side,  are  the  openings  of  Skene's 
tubules,  which  he  describes  as  lying  near  the  floor  of  the  urethra, 
just  beneath  the  mucous  membrane,  and  extending  parallel  to  the 
canal  about  three -fourths  of  an  inch.     Their  function  is  unknown. 

Their  orifices  can  usually  be  seen  by  everting  the  meatus  urin- 
arius. 

Bladder. 

Describe  it. 

The  bladder  is  a  hollow  musculo-membranous  organ,  situated  in 
the  pelvis  ' '  between  the  symphysis  pubis  in  front  and  the  vagina 
and  uterus  behind. ' ' 

The  bladder  presents  for  consideration  a  body,  a  base  or  fundus, 
and  a  neck.  The  body  is  all  that  portion  above  the  lines  joining  the 
ureteric  openings  and  the  centre  of  the  symphysis  pubis. 

All  below  these  lines  is  the  base  or  fundus.  The  portion  of  the 
fundus  between  the  urethral  and  ureteric  orifices  is  the  trigone. 

The  constricted  portion  continuous  with  the  urethra  is  the  neck. 

The  wall  of  the  bladder  consists  of  three  coats  :  a  peritoneal,  a 
muscular  and  a  mucous. 

The  peritoneal  coat  is  found  only  on  the  summit  of  the  bladder 
and  on  the  upper  part  of  the  posterior  surface.  The  muscular  coat 
consists  of  two  layers  :  an  outer  longitudinal  and  an  inner  circular ; 
the  latter  being  most  marked  around  the  urethral  orifice. 

The  mucous  membrane  consists  of  several  layers  of  transitional 
epithelium  resting  on  a  membrana  propria  ;  the  superficial  cells  are 
squamous.     It  contains  no  glands. 


BLADDER.  37 

The  mucous  membrane  is  thrown  into  numerous  folds,  except  at 
the  trigone,  where  it  is  more  closely  connected  with  the  underlying 
tissue. 

The  mucous  membrane  is  supported  by  a  submucous  layer  of  fibrous 
and  elastic  tissue,  containing  blood  vessels,  lymphatics  and  nerves. 

What  is  the  arterial  supply  of  the  bladder  and  urethra  ? 

The  bladder  receives  its  arterial  supply  from  the  superior,  middle 
and  inferior  vesical,  and  from  branches  of  the  uterine  and  vaginal 
arteries. 

They  are  all  derived  from  the  anterior  division  of  the  internal 
iliac. 

The  urethra  is  supplied  by  branches  from  the  vaginal  arteries. 

What  is  the  venous  supply  of  the  bladder  and  urethra  ? 

"  The  veins  form  a  complicated  plexus  round  the  neck,  sides  and 
base  of  the  bladder. ' '     (Gray. ) 

This  is  called  the  vesical  plexus  ;  it  lies  external  to  the  muscular 
coat  and  terminates  in  the  internal  iliac  vein. 

The  urethra  is  surrounded  by  a  venous  plexus  which  communi- 
cates with  the  vaginal  plexus. 

Give  the  lymphatic  and  nerve  supply  of  the  bladder  and 
urethra. 

The  lymphatics  of  the  bladder  and  urethra  empty  into  the  iliac 
glands.  Their  nerve  supply  is  derived  from  the  inferior  hypogas- 
tric plexuses  of  the  sympathetic  system,  and  from  the  3d  and  4th 
sacral  nerves  of  the  cerebrospinal  system. 

What  are  the  principal  venous  plexuses  of  the  pelvis  % 

The  vaginal  plexuses. 

The  vesical  plexus. 

The  hemorrhoidal  plexus. 

The  uterine  plexus. 

The  pampiniform,  or  ovarian  plexus. 

The  bulb  of  the  ovary. 

Describe  the  course  of  the  ureters  in  the  pelvis. 

The  ureters  cross  the  external  iliacs  just  beyond  the  bifurcation  of 
the  common  iliacs  ;  they  then  pass  downward  and  forward  along  the 
lateral  walls  of  the  pelvis,  enter  the  broad  ligaments,  and  run  forward 


38 


ESSENTIALS   OF   GYNAECOLOGY. 


and  inward.  At  the  level  of  the  internal  os  they  are  crossed  in  front 
by  the  uterine  arteries  (see  Fig.  4),  and  are  there  situated  about 
half  an  inch  from  the  uterus.  They  pass  alongside  of  the  vagina  a 
little  way,  converge  still  more,  enter  the  vesico-vaginal  septum,  and 
pierce  the  bladder  a  little  above  the  middle  of  the  anterior  vaginal 
wall ;  they  are  here  separated  two  inches  from  each  other  and  one- 
half  to  three-fourths  of  an  inch  from  the  cervix. 

Fig.  4. 


Drawing  from  a  dissection  made  to  show  relations  of  ureters,  uterine  arteries, 
bladder,  etc.    (J.  Greig  Smith.) 
ur.,  ureter;  ut.Ar.,  uterine  artery;  ou ,  os  uteri  exposed  by  an  incision,  x,  made 
through  the  top  of  the  vagina  ;  bl.,  bladder,  the  walls  of  which  are  cut  down  to  the 
insertion  of  the  ureters  into  its  base,  Vag.,  vagina. 


Rectum. 

Describe. 

The  rectum  is  the  lower  extremity  of  the  large  intestine,  about  8 
inches  in  length,  extending  from  near  the  left  sacro-iliac  synchron- 
drosis  to  terminate  in  the  anus  between  the  coccyx  and  perineum. 


RECTUM.  39 

It  presents  three  curves  :  — 

1.  Downward,  backward,  and  inward  to  the  third  sacral  vertebra. 

2.  Forward  to  the  apex  of  the  perineum. 

3.  Backward  to  the  anus. 

The  recent  anatomies  call  the  first  portion,  which  is  entirely- 
covered  by  peritoneum,  the  "pelvic  colon,"  and  restrict  the  term 
rectum  to  the  part  of  the  gut  uncovered  or  incompletely  covered  by 
peritoneum. 

It  consists  of  a  mucous  and  a  submucous  layer  and  two 
muscular  layers — a  longitudinal  and  a  circular,  the  former  being 
external. 

The  mucous  membrane  is  covered  with  columnar  epithelium  and 
contains  numerous  follicles  of  Lieberkiihn. 

At  its  lower  portion  the  mucous  membrane  is  thrown  into  perpen- 
dicular folds  called  columns  of  Morgagni ;  the  depressions  between 
them  being  called  the  sinuses  of  Morgagni. 

There  are  three  oblique  folds  of  importance,  including  not 
only  the  mucous  and  submucous  layers,  but  part  of  the  muscular 
coat. 

One  projects  from  the  anterior  wall  1 J  inches  from  the  anus. 

Another  is  on  the  right  side  near  the  sacral  promontory,  and  a 
third  is  situated  midway  between  the  two,  on  the  left  side. 

The  external  orifice  is  guarded  by  the  sphincter  ani  muscle  which 
surrounds  the  canal,  and  is  inserted  into  the  coccyx  behind  and  the 
perineum  in  front. 

Give  the  vascular  and  nerve  supply  of  the  rectum. 

The  arterial  supply  of  the  rectum  is  from  the  superior,  middle 
and  inferior  hemorrhoidal  arteries.  The  veins  form  a  plexus  beneath 
the  mucous  membrane  which  communicates  with  another  surround- 
ing the  exterior  of  the  canal ;  from  this  spring  veins  corresponding 
to  and  accompanying  the  arteries. 

The  superior  hemorrhoidal  vein  empties  into  the  inferior  mesen- 
teric of  the  portal  system. 

The  middle  and  inferior  hemorrhoidal  empty  into  the  internal 
iliac  of  the  general  venous  system. 

The  lymphatics  terminate  in  the  sacral  glands. 

The  nerves  are  derived  from  the  hypogastric  and  sacral  plexuses. 


40  ESSENTIALS   OF  GYNAECOLOGY. 

Give  the  relations  of  the  rectum. 

At  its  upper  portion  the  rectum  is  surrounded  by  peritoneum  and 
lies  in  direct  relation  anteriorly  with  the  cul-de-sac  of  Douglas. 

At  about  3  inches  from  the  anus  the  peritoneum  leaves  the  rectum, 
which  then  lies,  loosely  attached  to  the  posterior  wall  of  the  vagina 
for  1|  inches. 

The  remainder  is  separated  from  the  vagina  by  the  perineal  body. 

Posteriorly,  the  rectum  is  connected  at  its  upper  part  by  the  meso- 
rectum  to  the  sacrum ;  at  its  lower  part  by  fibrous  tissue  to  the 
sacrum  and  coccyx. 

On  each  side  it  receives  the  insertion  of  the  levatores  ani  and  is 
surrounded  below  by  the  sphincter  ani. 


Pelvic  Floor. 

Describe  the  segments  of  the  pelvic  floor. 

According  to  Dr.  Hart,  the  pelvic  floor  consists  of  two  segments  : 
the  pubic  and  sacral ;  the  pubic  consisting  of  the  bladder,  urethra, 
bladder  peritoneum  and  the  anterior  vaginal  wall ;  the  sacral  com- 
prising the  rectum,  perineal  body  and  posterior  vaginal  wall. 

According  to  the  same  authority,  also,  the  pubic  segment  is  made 
up  of  loose  tissue,  loosely  attached  to  the  pubes,  and  is  drawn  up 
during  labor  ;  the  sacral  segment  is  made  up  of  dense  tissue,  closely 
attached  to  sacrum  and  coccyx,  and  is  driven  down  during  labor. 

Describe  the  muscles  and  fascia  of  the  pelvic  floor,  as  dis- 
sected from  above. 

On  examining  the  pelvic  floor  from  abo',e,  we  find  the  pelvic  fascia 
attached  laterally  to  the  brim  of  the  pelvis,  to  the  spine  of  the 
ischium  behind,  to  the  lower  portion  of  the  symphysis  pubis  in 
front,  and  to  a  tendinous  band — "white  line  " — joining  the  two  latter 
points.  Behind  the  spine  of  the  ischium  the  pelvic  fascia  is  con- 
tinuous with  a  thin  layer  covering  the  pyriformis  muscle.  At  the 
1 '  white  line ' '  the  pelvic  fascia  divides  into  the  recto-vesical  fascia, 
which  covers  the  upper  surface  of  the  levator  ani  muscles,  and  the 
obturator  fascia,  covering  the  obturator  muscles.  The  recto-vesical 
fascia  arising  from  the  ' '  white  line ' '  extends  downward  and  inward, 
and  unites  in  the  median  line  with  its  fellow  of  the  opposite  side. 


PERINEAL  BODY.  41 

This  forms  a  fascial  diaphragm  which  is  perforated  by  the  rectum 
and  vagina,  to  each  of  which  it  is  firmly  attached  and  furnishes  a 
sheath  from  that  point  downward.  The  bladder  and  rectum  also 
receive  ligaments  from  this  fascia. 

On  removing  this  fascial  diaphragm,  we  meet  with  a  muscular 
diaphragm  formed  by  the  levator  ani  and  coccygeus  muscle  of  each 
side  meeting  in  the  median  line. 

The  coccygei  arise  from  the  ischial  spines,  and  are  attached  to  the 
sides  of  the  lower  segment  of  the  sacrum  and  to  the  sides  and  ante- 
rior surface  of  the  coccyx. 

The  levatores  ani  arise  from  the  posterior  aspect  of  the  pubes, 
from  the  spine  of  the  ischium  and  from  the  "white  line  "  of  the 
pelvic  fascia  connecting  these  points.  They  extend  downward  and 
backward  and  are  attached  to  the  vagina,  the  rectum,  to  each  other, 
and  to  the  tip  of  the  coccyx.  This  muscular  diaphragm  surrounds 
both  vagina  and  rectum. 

The  under  surface  of  this  muscular  diaphragm  is  covered  by  a  thin 
layer  of  fascia  which  is  attached  on  each  side  to  the  obturator  fascia. 
On  removing  the  muscular  diaphragm  with  its  upper  and  lower 
fascia,  there  remains,  filling  the  pelvic  outlet,  the  perineal  body,  the 
muscles  of  the  perineum  and  the  ischio-rectal  fossa. 


Perineal  Body. 

Describe. 

The  perineal  body  is  a  mass  of  muscular,  fibrous  and  adipose 
tissue,  somewhat  pyramidal  in  shape,  lying  between  the  lower  ends 
of  the  vagina  and  rectum  ;  it  measures  1$  inches  in  height,  lj 
inches  in  breadth  and  f  inch  antero-posteriorly.  Its  base  is  covered 
by  skin  which  is  sometimes  wrongly  spoken  of  as  "the  perineum," 
which  should  always  refer  to  the  perineal  body. 

The  muscles  which  are  attached  to  the  perineal  body  are  the 
bulbo-cavernosi,  transversi  perinei,  sphincter  and  levatores  ani. 

Give  the  vascular  and  nerve  supply  of  the  perineal  body. 

The  arterial  supply  of  the  perineal  body  is  from  the  internal 
pudics. 
The  veins  terminate  in  the  pudic  veins. 


42  ESSENTIALS   OF   GYNAECOLOGY. 

The  lymphatics  end  in  the  inguinal  glands. 
The  nerve  supply  is  from  the  pudic  nerve. 

What  are  the  functions  of  the  perineal  body  ? 

1 .  To  prevent  vaginal  rectocele. 

2.  To  help  form  a  compact  pelvic  floor. 

3.  To  serve  as  a  fixed  point  for  muscular  attachment. 

Muscles  of  the  Perineum. 

Name  and  describe  them. 

On  each  side  of  the  vaginal  orifice  we  find  three  muscles  :  bulbo- 
cavernosus,  ischio-cavernosus  or  erector  clitoridis,  and  the  trans- 
versa perinei. 

The  bulbo-cavernosus  arises  from  the  perineal  body  on  each  side 
of  the  vagina,  with  its  fellow  encircles  the  vaginal  bulbs  and  vesti- 
bule, and  divides  into  three  slips  ;  one  going  to  the  posterior  surface  of 
the  bulb,  another  to  the  under  surface  of  the  corpus  cavernosum  of 
the  clitoris,  and  the  third  to  the  mucous  membrane  of  the  vestibule. 

The  bulbo-cavernosi  compress  the  bulbs  of  the  vagina. 

The  transversus  perinei  arises  from  the  ramus  of  the  ischium  and 
is  lost  in  the  perineal  body. 

The  ischio-cavernosus  or  erector  clitoridis,  arises  from  the  front  of 
the  tuberosity  of  the  ischium  and  is  inserted  into  the  crus  clitoridis. 

These  muscles  are  supplied  by  the  internal  pudic  artery  and  by 
branches  of  the  pudic  nerve. 

The  veins  enter  the  pudic  veins. 

The  lymphatics  terminate  in  the  inguinal  glands. 

Ischio-rectal  Fossa. 

Give  its  gross  anatomy. 

It  is  a  pyramidal-shaped  area,  largely  filled  with  fat,  situated  on 
either  side  of  the  rectum ;  the  sides  are  formed  by  the  obturator 
internus  without  and  the  levator  ani  within  •  the  base  by  the  trans- 
versus perinei  and  the  lower  edge  of  the  gluteus  maximus. 

Describe  the  fascia  covering  the  pelvic  floor  below. 

From  without  inward  we  find  the  superficial  fascia  in  two  layers, 
the  external  being  continuous  with  the  general  superficial  fascia  of 
the  body.     The  deep  layer  is  attached  to  the  border  of  the  pubic 


PHYSICAL  EXAMINATION  OF  THE  FEMALE  PELVIC   ORGANS.      43 

arch  in  front  and  laterally ;  posteriorly,  it  passes  around  the  trans- 
versus  perinei  muscles  and  is  attached  to  the  base  of  the  anterior 
layer  of  the  triangular  ligament. 

Beneath  the  perineal  muscles  we  find  the  triangular  ligament, 
consisting  of  two  layers  of  fascia,  the  anterior  and  posterior,  filling 
in  the  pubic  arch. 


Development  of  the  Pelvic  Organs. 

Describe  briefly. 

In  the  latter  part  of  the  first  month  there  appear  in  the  foetus, 
on  either  side  of  the  primitive  vertebras,  the  urogenital  folds,  in 
which  develop  the  Wolffian  bodies,  which  play  the  part  of  tempo- 
rary kidneys.  They  soon  wither,  and  by  the  end  of  the  3d  month 
have  largely  disappeared,  but  their  remains  persist,  in  the  female, 
in  the  parovarium  and  Gaertner's  duct.  At  the  inner  side  of  the 
Wolffian  bodies  there  appears  an  invagination  of  the  germ  epithe- 
lium ;  this  develops  into  the  duct  of  Mueller,  one  for  each  Wolffian 
body.     These  coalesce  below  to  form  the  uterus  and  vagina. 

The  ovary  first  appears  as  a  white  ridge  on  the  inner  side  of  the 
Wolffian  body  ;  this  ridge  being  formed  of  connective  tissue  covered 
with  germ  epithelium  ;  from  the  former  is  developed  the  stroma  of 
the  ovary,  and  from  the  latter  are  formed  the  Graafian  follicles  and 
ova. 

Until  the  latter  part  of  the  second  month  of  foetal  life  the  urinary, 
genital  and  intestinal  canals  open  into  a  common  vault — the  cloaca. 
At  about  the  6th-7th  week  this  common  opening  is  divided  into  the 
anal  opening  posteriorly  and  the  uro-genital  anteriorly.  This  sepa- 
ration is  completed  by  the  formation  of  the  perineal  body  at  about 
the  tenth  week. 

The  uro-genital  canal  is  later  divided  into  the  urethra  anteriorly 
and  the  vagina  posteriorly. 


Physical  Examination  of  the  Female  Pelvic 

Organs. 

What  are  the  methods  of  examination? 
I.  Non-instrumental.     II.  Instrumental. 
I.  Non-instrumental. 


44  ESSENTIALS   OF  GYNECOLOGY. 

a.  Inspection  of  external  genitals. 

b.  External  abdominal  examination. 

c.  Vaginal  examination. 

d.  Bimanual  examination,  with  its  modifications. 

e.  Rectal  examination. 

What  positions  of  the  patient  are  used  in  gynaecological 
examinations  ? 

1.  Dorsal,  with  knees  and  thighs  flexed  and  feet  separated. 

2.  Lithotomy — same,  with  feet  raised  from  table. 

3.  Sims'  position. 

4.  Knee-chest  position. 

5.  Trendelenburg  position. 

6.  Standing  position. 

What  should  you  notice  on  inspection  of  the  external  gen- 
itals ? 

1.  Notice  whether  or  not  the  vulva  is  the  seat  of  venereal  sores 
warts,  abscesses,  pediculi,  etc. 

2.  Separate  labia  and  notice  condition  of  hymen  and  perineum, 
whether  intact  or  lacerated  ;  the  shape  of  hymen  if  intact.  If  peri- 
neum lacerated,  notice  whether  through  the  sphincter  ani  or  not ; 
notice,  also,  condition  of  urethra. 

3.  Tell  patient  to  strain,  and  with  labia  still  separated,  notice 
whether  anterior  or  posterior  vaginal  walls  prolapse  or  not,  thus 
forming  cystocele  or  rectocele. 

4.  During  this  inspection  it  is  well  to  pass  the  thumb  and  fore- 
finger along  each  labium  majus  to  ascertain  whether  the  vulvo- 
vaginal glands  or  their  ducts  are  enlarged  or  not. 

What  are  the  principal  elements  in  a  complete  external  ab- 
dominal examination  ? 

1.  Position  and  Preparation  of  patient. — Patient  should  be  on 
back  with  knees  drawn  up  ;  the  abdomen  should  be  uncovered  as 
low  down  as  the  pubes  ;  the  latter  not  being  exposed  ;  bladder  and 
rectum  should  be  empty. 

2.  Inspection. — Observe  the  form  and  color;  notice  whether 
irregularities  in  form  are  present  or  not. 

3.  Palpation. — Use  both  hands  ;  they  should  be  warm  ;  use  the 
.palms  and  palmar  surface  of  fingers  rather  than  their  tips  ;  employ 

very  little  force.     If  a  tumor  is  present,  notice  whether  it  is  solid  or 


VAGINAL  EXAMINATION.  4-J 

fluctuating,  whether  fixed  or  mobile  ;  if  possible,  determine  whether 
or  not  it  is  attached  to  one  of  the  pelvic  organs. 

Notice  whether  it  pulsates  or  is  the  seat  of  intermittent  contrac- 
tions. 

Palpate  inguinal  regions  for  enlarged  glands  or  herniae. 

4.  Percussion. — Patient  should  be  first  percussed  in  usual  manner 
while  lying  on  back  and  then  when  turned  on  either  side. 

Vaginal  Examination. 

Describe  the  method  of  performing  it. 

Have  the  patient  on  back  ;  knees  drawn  up  ;  if  a  married  woman, 
employ  two  fingers,  if  'unmarried,  use  one. 

Have  the  examining  finger  or  fingers  well  lubricated  and  folded 
into  the  palm  until  you  approach  the  vulva  ;  then  let  them  sweep 
over  the  perineum  and  fourchette  between  the  labia  till  they  enter 
the  vagina,  orifice.  Do  not  pass  from  above  downward  over  the 
clitoris.  After  entering  the  vagina  pass  the  finger  or  fingers  back- 
ward toward  the  hollow  of  the  sacrum. 

What  are  the  contraindications  to  a  vaginal  examination  ? 

A  vaginal  examination  should  not  be  made  in  an  unmarried 
woman  unless  there  are  strong  reasons  for  suspecting  trouble  with 
the  pelvic  organs,  and  then  only  in  the  presence  of  a  relative  or 
female  friend. 

It  should  not  be  made  during  a  normal  menstruation. 

What  is  the  value  of  a  vaginal  examination  per  se  ? 

The  value  of  a  vaginal  examination  by  itself  is  comparatively 
small ;  and  it  is  rarely  employed  save  as  a  part  of  a  bimanual 
examination. 

One  can,  however,  determine  the  following  points  by  a  vaginal 
examination,  and  they  should  be  carefully  noted  : — 

The  condition  of  perineum  and  vaginal  orifice. 
Presence  or  absence  of  Painful  Spots ; 
Spasm  ; 

Enlargement  of  vulvo-vaginal  glands ;  etc. 
Condition  of  vaginal  walls : — 

Heat; 
Moisture ; 


46  ESSENTIALS   OF   GYNAECOLOGY. 

Presence  or  absence  of 
Rugae ; 
New  growths ; 
Fistulas ;  etc. 
Projections  of  vaginal  walls  from 

Faeces  in  rectum ; 


Condition  of  cervix  :— 


Condition  of  os  : — 


Inflammatory  deposits ; 

Tumors  in  the  peritoneal  pouches. 

Position  ;  Density ; 

Shape ;  Mobility ; 

Size  ;  Lacerated  or  not 

Size  ; 

Shape ; 

Projections  through  it. 


Bimanual  Examination. 

What  is  the  method  of  performing"  it  ? 

The  position  of  the  patient  and  the  method  of  introducing  fingers 
are  the  same  as  for  the  vaginal  examination  just  described.  As 
regards  which  hand  shall  be  used  internally,  the  right  is  usually 
employed  first ;  but  to  make  a  complete  bimanual,  it  is  best  to 
employ  internally  the  right  hand  for  the  right  side  of  the  pelvis, 
and  the  left  hand  for  the  left ;  in  this  way  the  palmar  surfaces  of 
the  internal  and  external  fingers  are  approximated,  and  any  depart- 
ure from  the  normal,  on  either  side,  is  better  mapped  out  than 
when  the  right  hand  alone  is  used  for  the  internal  examination. 

Describe  the  use  of  the  external  hand  in  the  bimanual. 

The  ulnar  surface  of  the  external  hand  should  be  used  rather  than 
the  palm ;  it  should  be  applied  to  the  abdomen  some  distance  above 
the  pubes  and  steadily  depressed  toward  the  opposing  fingers  within 
the  vagina,  while  the  patient  relaxes  her  abdominal  muscles  and 
breathes  quietly,  with  mouth  open. 

Describe  the  use  of  the  internal  examining  fingers  in  the 
bimanual. 

While  the  ring  and  little  fingers  are  strongly  flexed  into  the  palm 
and  the  thumb  lies  on  the  pubes  or  between  the  thighs,  place  the 


BIMANUAL   EXAMINATION.  47 

middle  examining  finger  on  the  cervix  and  the  index  in  the  anterior 
fornix  and  raise  the  uterus  toward  the  external  hand.  The  first 
step  for  the  student  in  acquiring  skill  in  the  bimanual  is  to  feel, 
through  the  abdominal  wall,  a  body  which  transmits  motion  from 
the  external  hand  to  the  finger  on  the  cervix.  This,  in  a  normal 
case,  is  the  fundus  of  the  uterus  ;  future  examinations  will  enable 
one  to  map  out  more  and  more  the  shape  of  the  fundus. 

What  is  a  good  order  to  follow  in  making  a  bimanual  exam- 
ination ? 

1.  Determine  the  position  of  the  uterus  by  attempting  to  approxi- 
mate external  and  internal  fingers  ;  the  internal  being  placed  first  on 
cervix,  then  in  anterior  fornix  and  then  in  posterior ;  the  external 
hand  exerting  counter  pressure. 

2.  Determine  condition  of  tubes,  ovaries  and  parametria ;  using 
right  hand  internally  for  right  side  of  the  pelvis  and  left  for  left. 

Should  you  normally  feel  a  hard  body  in  any  of  the  four  for- 
nices  of  the  vagina  ?  If  so,  which  one,  and  what  is  it  ? 

Yes,  in  the  anterior  fornix  ;  the  body  of  the  uterus. 

Should  you  normally  feel  a  hard  body  in  the  posterior  or 
either  of  the  lateral  fornices  ? 

No. 

What  mass  might  you  feel  in  the  anterior  fornix  ? 

1.  A  fibroid  on  anterior  wall  of  the  uterus. 

2.  Inflammatory  or  blood  effusions,  rarely. 

What  mass  might  you  feel  in  either  of  the  lateral  fornices  % 

Inflammatory  deposit  from  cellulitis  or  peritonitis. 
Blood  effusion. 
Enlarged  tube  or  ovary. 
Body  of  uterus  latero-flexed. 
Lateral  fibroid. 
What  mass  might  you  feel  in  posterior  fornix  % 
Displaced  fundus. 
Faeces  in  rectum. 
Fibroid  on  wall  of  uterus. 
Peritonitic  or  cellulitic  deposit. 
Haematocele. 


48  ESSENTIALS   OF   GYNAECOLOGY. 

Displaced  ovary. 
Tumor. 

Rectal  Examination. 

What  are  the  methods  ? 

1.  Simple  rectal. 

2.  Abdomino -rectal. 

3.  Simon's  method. 

What  are  the  preliminaries  to  any  rectal  examination  ? 

Have  bowels  empty. 

Tell  patient  what  you  are  to  do. 

Have  soap  under  finger-nail. 

Lubricate  finger. 

Or,  better  still,  use  a  finger-cot. 

How  would  you  perform  the  simple  rectal  examination  ? 

Having  observed  the  preceding  preliminaries,  pass  the  finger  for- 
ward, noting  the  presence  or  absence  of  hemorrhoids,  fissures,  polypi, 
stricture,  etc. ,  till  the  cervix  is  felt,  then  pass  along  posterior  wall 
of  the  uterus. 

How  would  you  perform  the  abdomino-rectal  examination  ? 

Passing  the  right  index  finger  into  the  rectum  as  just  described, 
use  the  left  hand  externally,  placed  on  the  abdomen  as  in  the  i>rdi- 
nary  bimanual. 

What  is  Simon's  method  ? 

This  consists  in  passing  the  whole  hand,  shaped  like  a  cone, 
gradually  through  the  anus  into  the  rectum. 

What  is  the  value  of  the  different  methods  of  rectal  exami- 
nation ? 

Both  the  simple  rectal  and  abdomino-rectal  are  of  especial  value 
in  virgins,  where  the  ordinary  bimanual  is  painful  or  objected  to. 

By  means  of  a  volsella  forceps  you  may  draw  down  the  cervix,  and 
then,  with  finger  in  the  rectum,  palpate  the  posterior .  surface  of 
uterus,  tubes  and  ovaries. 

The  above  methods  of  rectal  examination  are  of  value  in  any  case 
where  you  wish  to  reach  higher  than  is  possible  with  the  ordinary 
bimanual. 

Advantage  is  sometimes  gained  by  making  the  rectal  examination 
with  patient  in  Sims'  position. 


INSTRUMENTS — SPECULA. 


49 


Simon's  method  is  dangerous  and  seldom  justifiable. 

What  are  the  instrumental  methods  of  rectal  examination  ? 

Where  information  is  sought  regarding  the  rectum  itself  rather 
than  adjacent  organs,  the  Sims  position  or  the  knee-chest  position 
are  employed.  The  speculum  most  generally  useful  in  exploring 
the  lower  rectum  is  a  small  Sims'.  It  is  inserted  slowly,  the  patient 
is  asked  to  strain  so  that  the  mucosa  prolapses,  and  then  the  speculum 
is  shifted  from  side  to  side 
till  all  parts  of  the  mucosa  Fig.  5, 

have  been  examined. 

For  examination  higher  up 
an  instrument  like  the  Kelly 
cystoscope  is  useful.  For 
most  complete  and  thorough 
examination  of  the  rectum 
and  pelvic  colon  the  Tuttle 
proctoscope  is  admirable. 
This  instrument  consists  of 
a  tube  with  concealed  light, 
and  is  closed  at  the  proximal 

end  by  a  glass  window.  There  is  also  an  attachment  for  distending 
the  rectum  with  air.  The  rectum  is  distended  and  the  instrument 
advanced  to  succeeding  rectal  segments,  guided  by  sight  through  the 
proctoscope. 


Sims'  Speculum 


INSTRUMENTS. 

Specula. 

What  are  the  three  classes  of  specula  in  most  common  use  ? 

1.  TheSpatular. 

2.  The  Cylindrical 

3.  The  Bivalve. 

Give  one  of  the  best  examples  of  the  spatular  variety; 
describe  it. 

The  Sims  speculum  (see  Fig.  5)  is  the  best  example  of  this  class  ; 
it  consists  of  two  blades  united  by  a  handle  at  right  angles  to  them, 
4 


50  ESSENTIALS   OF   GYNECOLOGY. 

the  blades  being  convex  on  the  sides  facing  each  other,  concave  on 
the  opposite.  Many  modifications  are  made  by  which  the  length 
of  blade,  angle  at  which  it  joins  the  shaft,  and  weight  of  the  whole 
instrument  are  altered.  One  blade  of  the  Sims  speculum  is  usually 
made  shorter  and  smaller  than  the  other. 

What  are  the  advantages  of  Sims'  speculum  ? 

It  does  not  distort  cervix. 

It  gives  a  good  view  of  all  but  the  posterior  vaginal  wall,  and  is 
the  best  suited  for  operations  on  cervix  and  anterior  vaginal  wall. 

What  are  the  disadvantages  of  Sims'  speculum  ? 

It  requires  an  assistant  with  some  training  to  hold  it. 

It  requires,  in  most  cases,  the  use  of  a  vaginal  depressor,  thus 
employing  one  hand. 

What  is  the  proper  position  of  the  patient  for  the  use  of  Sims' 
speculum  ? 

A  patient  in  the  so-called  ' '  Sims  position  ' '  should  lie  on  her  left 
side,  with  left  buttock  on  the  left  corner  of  the  table,  as  you  ftice  it ; 
the  head  being  at  the  right  corner  of  the  head  of  the  table,  the  left- 
arm  behind  the  patient ;  the  right  arm  should  lie  over  the  right 
edge  of  the  table,  the  right  shoulder  being  kept  as  near  the  table  as 
possible.  The  knees  should  be  drawn  up,  the  right  a  little  above 
the  left. 

How  would  you  introduce  a  Sims  speculum  ? 

Having  placed  the  patient  in  the  correct  Sims  position,  select  the 
blade  you  are  to  use ;  warm  and  lubricate  the  convex  side  of  it ; 

Fig.  6. 


take  the  speculum  in  the  right  hand  with  the  index  finger  lying  in 
the  concavity  of  the  blade,  and  introduce  finger  and  blade  together. 


INSTRUMENTS — SPECULA. 


51 


The  breadth  of  the  blade  should  be  in  line  with  the  labia  until  it 
has  entered  the  vaginal  orifice  ;  it  should  then  be  rotated  till  the 
convexity  lies  in  apposition  with  the  posterior  vaginal  wall,  which  it 
should  hug  closely  till  the  posterior  fornix  is  reached  and  the  index 
finger  detects  the  cervix  in  front  of  it ;  the  speculum  is  then  given 
to  an  assistant  to  hold.  Some  introduce  the  finger  first  and  pass 
the  blade  along  it. 

Fig.  7. 


Simon's  Speculum. 

How  would  you  hold  a  Sims  speculum  ? 

There  are  two  methods  in  common  use  : — 

(a)  One  is  to  grasp  the  outside  blade  with  the  right  hand,  the 
angle  between  blade  and  handle  fitting  over  index  finger,  as  seen  in 
Fig.  6  ;  the  thumb  lying  in  the  concavity  of  the  blade  over  the 
angle. 

The  right  buttock  should  be  raised  with  the  left  hand. 

(b)  The  other  method  is  to  grasp  the  handle  of  the  speculum  with 
the  right  hand,  having  the  convexity  of  the  outside  blade  rest  in 
the  hollow  between  the  thumb  and  index  finger. 

The  right  buttock  being  raised  as  in  the  other  method. 

What  is  a  Simon's  speculum  % 

A  very  valuable  speculum  of  the  spatular  variety  is  called  Simon's 
(see  Fig.  7.)  It  consists  of  a  common  handle  into  which  fit,  at 
right  angles  to  it,  blades  of  different  sizes  and  shapes.  It  is  of 
especial  value  with  the  patient  in  the  dorsal  position,  for  retracting 
the  perineum  in  curetting  the  uterus  or  operating  upon  the  cervix. 


52 


ESSENTIALS   OF  GYNAECOLOGY. 


What  is  one  of  the  best  examples  of  a  cylindrical  speculum  ? 
Describe  it. 

The  cylindrical  speculum  of  Fergusson  (see  Fig.  8)  is  probably  the 
best  of  its  class  ;  it  is  a  cylinder  of  glass  or  hard  rubber,  with  one 
extremity  beveled  and  the  other  trumpet-shaped. 

The  glass  ones  usually  present  a  mirrored  surface  from  within. 

The  beveled  extremity  is  the  one  first  introduced. 


Fig.  8. 


Fergusson's  Speculum, 


What  are  the  merits  of  the  Fergusson  speculum  ? 

It  is  of  very  limited  use ;  it  may  be  employed  for  inspecting  the 
cervix  and  vaginal  wall  or  making  applications  to  it.  It  is  useless 
for  operations  on  the  cervix ;  it  is  only  partially  self-retaining,  and 


Fig.  9. 


Brewer's  Speculum. 


its  introduction  in  nulliparae  is  painful.     It  is  sometimes  used  for 
introducing  gauze  packing  into  the  vagina. 

How  would  you  introduce  a  Fergusson  speculum  ? 

In  this  country  the  Fergusson  speculum  is  usually  employed  with 
the  patient  in  the  dorsal  position. 


INSTRUMENTS — SPECULA. 


06 


Separate  the  labia  with  the  fingers  of  the  left  hand  ;  holding  the 
trumpet-shaped  extremity  with  the  right  hand,  introduce  the 
beveled  extremity  into  the  vaginal  orifice,  having  the  shorter  side 
anterior  ;  depress  well  the  perineum,  directing  the  speculum  toward 
the  hollow  of  the  sacrum  ;  by  slight  vertical,  horizontal  or  rotatory 
motion  of  the  speculum  while  looking  into  it,  the  cervix  is  now 
usually  brought  into  view  without  difficulty.  It  is  occasionally 
convenient  to  draw  the  cervix  more  fully  into  view  by  means  of  a 
tenaculum. 

Some  gynaecologists  use  the  Fergusson  speculum  with  the  patient 
in  Sims'  position. 

Fig.  n. 


Kelly's  speculum  ready  for  introduction  (a);  b,  speculum  with  obturator  removed 


What  is  one  of  the  best  examples  of  a  bivalve  speculum? 
Describe  it. 
The  Brewer  bivalve  (see  Fig.  9)  is  probably  the  best  speculum 
of  its  class ;  it  consists  of  two  blades,  the  outer  extremities  being 
trumpet-shaped  where  they  are  jointed  ;  the  anterior  blade  is  shorter 
than  the  posterior,  and  has  a  slot  in  its  outer  half,  to  avoid  pressure 
on  the  urethra  ;  this  also  facilitates  the  introduction  of  the  sound  or 
probe.  The  speculum  is  opened  by  approximating  the  handles  of 
the  blades  and  held  there  by  a  thumb-screw.  There  are  two  sizes 
of  Brewer's  speculum,  the  long  and  short. 


54  ESSENTIALS   OF  GYNAECOLOGY. 

How  would  you  introduce  a  Brewer  speculum  ? 

Place  patient  in  dorsal  position ;  pass  speculum  into  vaginal  orifice 
with  the  blades  lateral,  then  rotate  till  they  are  antero-posterior ; 
begin  to  open  blades  just  before  they  reach  the  cervix ;  when  com- 
pletely open,  hold  with  thumb-screw. 

What  are  the  merits  of  Brewer's  speculum  ? 

For  inspection  of,  and  applications  to,  the  cervix,  it  is  very  valu- 
able ;  it  is  self-retaining,  thus  obviating  the  necessity  of  an  assistant. 

The  long  instrument  is  better  than  the  short,  as  with  it  the 
vaginal  walls  are  not  as  likely  to  obstruct  the  view  by  falling  in  be- 
yond the  blades,  and  at  the  same  time  it  accomplishes  all  that  the 
short  instrument  does. 

What  are  the  disadvantages  of  Brewer's  speculum? 

It  distorts  the  cervix,  obscures  the  anterior  vaginal  wall,  and  can- 
not be  used  for  operations  on  the  cervix  or  vagina. 

What  is  a  simple  speculum  for  examination  of  the  interior  of 
the  bladder? 

The  simplest  speculum  for  direct  inspection  of  the  interior  of 
the  bladder  is  that  devised  by  Dr.  Kelly,  of  Baltimore  (Fig.  9J). 
It  is  a  tubular  speculum  with  obturator,  and  comes  in  several 

sizes. 

Describe  its  use. 

The  bladder  is  emptied  ;  the  patient  is  placed  in  an  exaggerated 
lithotomy  position,  with  hips  elevated  8  to  16  inches  above  the 
table.  One  of  the  smaller  sized  specula  is  introduced,  and  then 
a  larger,  until  the  desired  size  is  reached.  The  obturator  is  then 
withdrawn,  and  air  enters  and  distends  the  bladder.  The  residual 
urine  is  removed  by  pledgets  of  cotton  held  in  long  thumb-forceps ; 
light  is  thrown  into  the  bladder  by  means  of  a  forehead  mirror,  and 
by  turning  the  speculum  in  different  directions  nearly  the  whole  of 
the  interior  of  the  bladder  may  be  inspected,  and  through  the  spec- 
ulum the  ureters  may  be  catheterized. 

For  a  thorough  examination  anaesthesia  is  desirable. 

Sometimes  during  such  an  examination  the  bladder  will  not  dis- 
tend sufficiently  with  air.  In  such  cases  the  object  can  be  accom- 
plished by  putting  the  patient  in  the  knee-chest  position. 


INSTRUMENTS — VOLSELLA. 


55 


Fig.  10. 


What  other  types  of  specula  are  used  ? 

The  simple  Kelly  tubes  have  been  replaced  by  more  elaborate 
instruments,  which  can  be  used  without  pain  and  without  either 
local  or  general  anaesthesia.  These  instruments  are  used  with  the 
patient  in  the  dorsal  position,  and  the  bladder  is  distended  to  a 
capacity  of  six  ounces  or  over,  either  with  air  or  water,  according  to 
the  instrument  used.  They  consist  of  a  hollow  tube,  with  an  elec- 
tric light  attached  to  the  end  which  enters  the  bladder  and  which 
illuminates  its  interior.  Into  this  tube  is  passed 
the  telescope  of  the  instrument.  These  are  of 
two  kinds,  the  direct  vision  and  indirect  vis- 
ion cystoscopes.  In  the  former  one  sees  the 
portion  of  bladder  wall  lying  in  line  with  the 
axis  of  the  instrument ;  in  the  indirect  vision 
cystoscope  the  object-glass  is  placed  on  the 
side  of  the  telescope,  hence  one  sees  a  portion 
of  bladder  wall  at  right  angles  to  the  axis  of 
the  instrument.  Most  of  the  instruments  are 
equipped  with  ureteral  catheterizing  attach- 
ments. The  Nitze  and  Otis  instruments  are 
good  examples  of  the  simple  indirect  vision- 
examining  cystoscope. 


Volsella. 

Describe  it. 

The  volsella,  or  vulsellum  forceps  (see  Fig. 
10),  consists  of  a  pair  of  hooks  with  scissor 
handles  and  joint ;  the  hooks  usually  con- 
sist of  two  or  more  teeth ;    the   handles  fasten  with  a  catch. 


What  are  the  uses  of  the  volsella  ? 

In  all  operations  on  the  cervix,  trachelorrhaphy,  dilatation,  etc., 
the  volsella,  or  one  of  its  substitutes,  is  almost  indispensable,  to 
draw  down  and  hold  the  cervix. 

For  applications  to,  or  operations  on,  the  interior  of  the  body  of 
the  uterus,  the  volsella  is  also  of  great  value. 

The  use  of  the  volsella  to  draw  down  the  cervix,  in  connection 


56  ESSENTIALS   OF  GYNECOLOGY. 

with  the  finger  in  the  rectum,  in  the  combined  rectal  examination, 
is  of  great  importance. 

How  would  you  introduce  and  apply  the  volsella? 

If  used  in  operation  on  the  cervix  with  the  patient  in  the  Sims 
position,  it  may  be  introduced  either  without  or  with  the  use  of  the 
speculum  ;  if  without  the  speculum,  the  first  two  fingers  of  the  right 
hand  are  introduced  till  the  anterior  lip  of  the  cervix  is  felt ;  the 
volsella  is  then  passed  along  them  and  applied  to  the  anterior  lip, 
which  is  then  drawn  down. 

The  better  way  is  usually  to  employ  Sims'  speculum  and  apply 
the  volsella  directly  to  the  anterior  lip  by  sight. 

The  volsella  is  also  employed  with  the  patient  in  the  dorsal  position, 
the  instrument  being  introduced  either  by  touch,  or  sight  aided  by 
a  perineal  retractor. 

Fig.  11. 


Sir  J.  Y.  Simpson's  Sound. 


What  could  you  substitute  for  a  Volsella  ? 

A  bullet  forceps  with  a  catch  makes  a  very  good  substitute  for  a 
volsella  and  is  getting  to  be  preferred  to  it,  as,  having  but  one  pair 
of  teeth,  it  occupies  less  space  on  the  cervix. 

A  tenaculum,  such  as  Sims',  which  is  a  sharp  hook  on  a  long 
slender  shank,  is  often  of  great  use  in  holding  the  cervix  and  draw- 
ing it  in  any  direction,  and  can  sometimes  be  substituted  for  a  vol- 
sella. 

Uterine  Sound. 

What  are  the  two  sounds  in  most  general  use  ?  their  descrip- 
tion and  merits  ? 

The  Sir  J.-Y.  Simpson's  sound  and  that  of  A.  R.  Simpson  are 
the  two  in  most  general  use. 

They  are  both  rods  of  copper,  nickel-plated,  and  so  pliable  that 
they  can  easily  be  bent  with  the  fingers. 


INSTRUMENTS — UTERINE   SOUND. 


57 


The  sound  of  Sir  J.  Y.  Simpson  (see  Fig.  11  j  is  12  inches  long, 
with  a  notched  knob  2§  inches  from  the  end,  and  notches  at  ?>\.  \\. 
etc. ,  up  to  8 i  inches. 

The  handle  is  roughened  on  the  side  of  the  concavity  of  the 
curve. 

The  sound  of  A.  R.  Simpson  (see  Fig.  12)  is  only  9  inches  long  ; 
it  has  a  prominent  ring  at  2§-  inches  and  two  rings  at  4J  inches ; 
there  are  also  markings  at  3J  and  5  J  inches.  This  sound  has  an 
advantage  over  the  preceding  in  that,  being  only  9  inches  long,  the 
handle,  which  is  broad,  can  rest  firmly  on  the  ball  of  the  little  finger 
even  when  the  tip  of  the  index  finger  is  on  the  2\  inch  ring,  thus 
giving  one  a  complete  control  of  the  instrument  when  the  finger  is 
in  the  vagina  with  the  sound.     This  is  impossible  with  the  sound  of 

Fig.  12. 


A.  R.  Simpson's  Sound.    (Hart  and  Barbour.) 


Sir  J.  Y.  Simpson,  as  in  similar  circumstances  the  handle  is  far 
above  the  hand,  and  one  can  only  grasp  the  shank,  which  readily 
rotates.  The  presence  of  the  double  ring  is  also  an  advantage  in  an 
enlarged  uterus. 


What  are  the  contraindications  to  the  use  of  the  sound  ? 
Patient  has  skipped  a  menstrual  period. 
Menstruation  present. 

Acute  inflammation  present  in  uterus  or  neighborhood. 
Malignant  disease  of  uterus. 


58  ESSENTIALS  OF  GYNECOLOGY. 

What  are  the  preliminaries  to  the  use  of  the  sound  ? 

1.  Thoroughly  sterilize  the  sound. 

2.  Be  sure  that  the  patient  has  not  skipped  a  menstrual  period. 

3.  Determine  position  of  uterus  by  a  careful  examination. 

4.  Curve  sound  to  the  curve  of  the  uterus. 

5.  Cleanse  the  vagina  with  an  antiseptic  solution.  This  is  of  im- 
portance to  avoid  carrying  septic  material  from  vagina  to  uterus  by 
the  sound.  For  this  reason  it  is  always  wiser  to  introduce  the  sound 
with  the  aid  of  a  speculum,  which  separates  the  vaginal  walls  and 
enables  you  to  reach  the  os  directly. 

6.  Position  of  the  patient  :— 

This  is  largely  a  matter  of  choice,  but  in  this  country  the  dorsal 
position  is  usually  selected,  and  it  has  the  advantage  that  in  this 
position  the  bimanual  may  be  easily  combined  with  the  use  of  the 
sound. 

How  would  you  introduce  the  sound  with  patient  in  the  dor- 
sal position  ? 

Having  introduced  a  speculum  and  thoroughly  cleansed  the 
vagina,  be  sure  your  sound  is  aseptic  and  then  pass  it  by  sight 
directly  into  the  os.  The  introduction  is  often  most  easily  accom- 
plished if  the  uterine  body  lies  forward  by  starting  the  sound  with 
its  concavity  backward,  then,  when  the  point  is  engaged  in  the  cer- 
vical canal,  turning  the  sound,  not  by  rotating  the  shank,  but  by 
making  the  handle .  describe  a  semicircle  from  behind,  to  the  left 
and  forward  ;  the  point  of  the  instrument  remaining  nearly  station- 
ary. By  depressing  the  handle  toward  the  perineum,  the  sound 
will  then  usually  pass  without  trouble.  If  the  point  catches  in  the 
crypts  of  the  cervix,  slight  motion  will  usually  disengage  it. 

What  variation  in  this  procedure  would  you  make  if  the 
fundus  lay  posteriorly? 

Having  introduced  the  sound  into  the  cervix  as  before,  with  con- 
cavity backward,  continue  the  introduction  without  the  semicircular 
motion  of  the  handle. 

In  this  position  of  the  fundus  the  sound  is  sometimes  most  easily 
introduced  by  a  maneuver  similar  to  that  in  the  preceding  case  but 
in  the  opposite  direction,  viz.,  starting  with  the  concavity  of  the 


INSTRUMENTS— UTERINE  SOUND.  59 

sound  forward,  make  the  handle  describe  a  semicircle  from  before 
backward. 

How  would  you  pass  the  sound  in  a  marked  case  of  ante- 
flexion ? 

If  the  uterus  is  anteflexed,  the  introduction  of  the  sound  is  facili- 
tated by  curving  the  sound  sharply,  and  drawing  down  and  steady- 
ing the  cervix  with  a  bullet  forceps. 

How  would  you  introduce  the  sound  with  patient  in  Sims' 
position  ? 

Here,  as  in  the  dorsal  position  of  the  patient,  the  introduction 
of  the  sound  should  be  preceded  by  the  introduction  of  the  specu- 
lum and  the  cleansing  of  the  vagina  and  cervix  ;  the  sound  rendered 
aseptic  is  then  passed  by  sight  directly  into  the  os  without  being- 
allowed  to  touch  the  vaginal  walls :  in  this  way  the  introduction  of 
sepsis  into  the  uterus  is  avoided.  The  further  introduction  of  the 
sound  may  be  continued  with  the  concavity  forward,  or  starting 
with  the  concavity  backward  the  semicircular  motion  of  the  handle 
from  behind  forward  may  sometimes  be  employed  with  advantage. 

If  the  uterus  lies  posterior,  the  sound  can  usually  be  introduced 
directly  with  its  concavity  backward. 

What  are  the  uses  of  the  uterine  sound  ? 

(a)  To  determine — 1.  The  length  of  uterine  canal. 

2.  Its  permeability. 

3.  Its  direction. 

4.  Condition  of  endometrium. 

5.  Growths  in  uterus. 

6.  Relation  of  uterus  to  tumors. 

(b)  To  replace  a  displaced  uterus. 

The  mobility  of  the  uterus  and  the  relation  of  cervix   and  body 
should  be  determined  by  the  bimanual,  not  by  the  sound. 
The  sound  is  wisely  much  less  used  now  than  formerly. 

What  are  the  dangers  in  the  use  of  the  sound  ? 

1.  Pelvic  peritonitis  or  cellulitis,  from  introduction  of  sepsis. 

2.  Abortion. 

3.  Hemorrhage,  especially  in  malignant  disease. 

4.  Perforation  of  uterine  walls. 


60  ESSENTIALS   OF   GYNECOLOGY. 


Uterine  Probe. 

Give  its  description  and  uses. 

The  uterine  probe  is  usually  a  slimmer  instrument  than  the  sound, 
made  of  silver,  hard  rubber  or  whalebone,  with  end  slightly  bulbous. 
Except  in  cases  of  stenosis,  it  is  harder  to  introduce  than  the  sound, 
and  of  less  general  value.  It  should  be  introduced  by  sight,  while 
cervix  is  steadied  with  a  tenaculum. 


Uterine  Applicator. 

Give  its  description  and  uses. 

It  is  usually  made  of  a  piece  of  flexible  steel  or  copper  wire 
flattened  at  one  end  and  attached  to  a  handle  at  the  other.  It  is 
used  to  apply  medication  to  the  uterine  mucosa.  The  applicator  is 
thrust  into  a  small  piece  of  cotton  held  between  the  thumb  and 
finger.  It  is  then  rotated  until  the  cotton  is  so  firmly  twisted  about 
the  end  that  it  cannot  be  easily  pulled  off.  It  is  then  dipped  into 
the  fluid  to  be  used  and  inserted  in  the  same  manner  as  the  uterine 
sound.  As  a  general  rule  it  is  safer  to  make  such  applications  only 
to  the  cervix. 

Dilators. 

What  are  the  methods  of  dilating  the  cervical  canal  ? 

1.  By  tents. 

2.  By  graduated  hard  dilators. 

3.  By  dilators  of  the  glove-stretcher  variety. 

4.  By  elastic  dilators — Barnes'  bag  or  Allen's  pump. 

Tents. 

What  do  you  mean  by  a  tent  as  employed  in  gynaecology  ? 
Give  the  varieties  in  use. 

A  tent  is  a  cone  of  some  expansile  material,  which,  by  absorption 
of  moisture,  expands  after  introduction  into  the  cervix  sufficiently, 
both  in  extent  and  force,  to  dilate  the  canal. 


INSTRUMENTS — GRADUATED   HARD   DILATORS.  61 

There  are  several  varieties  of  tents  in  use,  named  according  to 
their  material. 

1.  Sponge. 

2.  Sea-tangle  (Laminaria  digitata). 

3.  Tupelo  (Nyssa  aquatilis). 

4.  Cornstalk. 

What  are  the  merits  of  each  ? 

The  sponge  tent  expands  easily,  but  it  is  the  most  dangerous  of 
all,  from  the  fact  that  it  absorbs  so  readily  material  which  easily 
becomes  septic. 

The  sea-tangle  tent  is  less  dangerous  than  the  preceding,  and 
dilates  well,  but  it  expands  unevenly,  and  its  edges  are  rough  after 
expansion. 

The  tupelo  tent  is  the  best  of  all.  It  expands  evenly  and  smoothly, 
and  is  the  least  liable  to  cause  sepsis. 

The  cornstalk  is  feeble  in  action  and  seldom  used. 

What  are  the  indications  for  the  use  of  tents  ? 

1.  To  dilate  the  cervical  canal  for  purposes  of  diagnosis  or  opera- 
tion. 

2    To  check  hemorrhage. 

What  are  the  merits  of  tents  for  these  uses  ? 

The  employment  of  tents  has  greatly,  and  very  wisely,  diminished 
of  late.  For  diagnostic  purposes  they  are  still  occasionally  employed 
to  dilate  the  cervical  canal,  so  that  the  finger  can  be  introduced,  but 
they  are  dangerous,  slow  and  painful,  and  we  have,  in  most  cases, 
better  means,  in  dilators  of  the  glove-stretcher  variety,  for  accom- 
plishing the  same  result. 

The  use  of  tents  to  check  hemorrhage  was  chiefly  in  abortion  ;  the 
dilatation  of  the  canal  being  sought  for  at  the  same  time.  We  now 
have  better  means. 


Graduated  Hard  Dilators. 

Describe  them. 

There  are  several  varieties  in  common  use,  among  which  are  Peas- 
lee's,  Kammerer's,  Hank's,  etc. 


62  ESSENTIALS  OF  GYNAECOLOGY. 

The  first  two  resemble  male  sounds,  except  that  the  curve  is  less 
acute,  and  at  1\  inches  there  is  a  bulb. 

Hank's  dilators  consist  of  two  sounds  on  each  handle,  one  at  each 
end.     They  are  often  made  in  sets  of  six  and  of  hard  rubber. 

Ordinary  male  sounds,  Nos.  15  to  18,  French,  may  often  be  sub- 
stituted for  the  dilators  just  mentioned. 

What  are  indications  for  the  use  of  graduated  hard  dilators  ? 

1.  By  themselves  to  dilate  a  stenosis  of  the  cervix  causing  dys- 
menorrhea or  sterility.  Under  stenosis  here  is  included  that  caused 
by  flexions. 

2.  To  maintain  a  dilatation  produced  by  one  of  the  more  power- 
ful dilators. 

Describe  the  mode  of  employment  of  these  graduated  hard 
dilators. 

Place  the  patient  in  the  dorsal  position ;  thoroughly  cleanse  the 
vagina  and  expose  the  cervix  with  a  speculum  ;  draw  down  and  hold 
cervix  with  a  tenaculum  or  volsella ;  introduce  dilator  by  sight,  as 
you  would  the  uterine  sound,  beginning  with  the  smallest  size  and 
increasing  to  the  largest.  Pack  the  vagina  loosely  with  iodoform 
gauze  or  sterilized  gauze. 

In  employing  these  graduated  dilators  for  stenosis  of  cervix 
causing  obstructive  dysmenorrhea,  how  often  should 
they  be  introduced? 

It  is  usually  necessary  to  introduce  them  once  a  week  during  the 
first  month,  and  once  or  twice  a  month  for  a  few  months  afterward  ; 
exercising  each  time  the  same  antiseptic  precautions. 

Describe  the  dilators  of  the  glove-stretcher  variety. 

The  two  chief  styles  of  these  are  the  Sims  and  Ellinger's ;  in  the 
latter  of  which  the  blades  are  caused  to  move  parallel,  and  on  the 
handle  there  is  a  graduated  scale.  There  are  numerous  modifica- 
tions of  these  dilators,  among  which  may  be  mentioned  Wylie's  and 
Goodell's. 

What  are  the  indications  for  the  employment  of  these  dila- 
tors? 

The  same  indications  obtain  as  for  the  preceding,  and  in  addition 
where  a  more  complete  dilatation  of  the  cervix  is  desired. 
The  first  and  more  complete  dilatation  is  often  performed  with  a 


ELASTIC  DILATORS— BARNES'  BAGS,  ALLEN'S  PUMP.  63 

dilator  of  this  class,  and  then  the  dilatation  maintained  by  the 
graduated  hard  dilators. 

What  are  the  preliminaries  to  the  use  of  the  glove-stretcher 
dilators  ? 

The  patient  should  have  an  antiseptic  douche,  and  for  complete 
dilatation,  anaesthesia. 

Describe  the  method  of  employing  these  dilators. 

The  patient  is  usually  placed  in  the  dorsal  position.  Retract  the 
perineum  with  a  Simon's  speculum  ;  thoroughly  cleanse  the  vagina 
and  cervix ;  draw  down  and  steady  the  cervix  with  a  bullet  forceps 
and  introduce  dilator  to  the  shoulder,  separate  blades  gradually  to 
the  desired  extent,  being  careful  that  the  instrument  does  not  slip 
suddenly  and  lacerate  the  cervix.  While  most  of  the  dilatation  is 
performed  in  the  lateral-diameter  of  the  cervix,  it  is  often  well  to 
rotate  the  dilator  and  dilate  somewhat  in  other  diameters.  The 
dilatation  may  also  be  performed  with  the  patient  in  Sims'  posi- 
tion and  with  the  aid  of  Sims'  speculum. 

To  what  extent  should  you  carry  the  dilatation? 

Usually  from  %  to  1  inch. 


ELASTIC  DILATORS. 
Barnes'  Bags,  Allen's  Pump. 

Describe  them  and  the  method  of  using  them. 

They  consist  of  India-rubber  bags,  of  different  sizes,  the  former 
being  fiddle-shaped,  the  latter  more  elongated.  They  are  intro- 
duced under  strict  antiseptic  precautions,  in  a  collapsed  condition, 
and  are  then  slowly  distended  with  air  or  water,  usually  the  former  ; 
the  Barnes'  bags  by  means  of  a  Davidson's  syringe,  Allen's  by  the 
pump. 

What  are  the  advantages  of  these  elastic  dilators  ? 

Their  method  more  closely  resembles  the  physiological  method  of 
dilating  the  cervix ;  the  dilatation  can  be  made  extensive  ;  the 
danger  of  laceration  of  the  cervix  is  slight. 


64  ESSENTIALS   OE  GYNECOLOGY. 

They  are  chiefly  used  to  start  labor  or  abortion  after  the  third 
month  of  pregnancy. 

What  are  the  dangers  of  mechanical  dilatation  ? 

Laceration  of  the  cervix. 
Endometritis. 
Salpingitis. 
Peritonitis. 

Stem  Pessaries. 

Describe  them  and  their  uses. 

They  consist  of  a  hard-rubber  or  non-corrosive  metal  rod  about  If 
inches  long,  at  one  end  of  which  a  wide  flange  projects  to  keep  the 
pessary  from  slipping  too  far  into  the  uterus.  There  is  usually  a 
groove  in  the  rod  or  else  it  is  hollow  to  allow  the  escape  of  secretion. 
Their  use,  which  is  to  maintain  a  dilatation  of  the  cervix,  accom- 
plished in  one  of  the  above-mentioned  ways,  is  attended  with  con- 
siderable danger  if  not  introduced  with  aseptic  precautions  or  if  left 
in  for  too  long  a  time. 


The  Curette. 

Describe  it. 

The  curette  consists  usually  of  a  loop  of  wire,  either  blunt  or 
sharp,  on  a  rather  long  shank,  used  for  scraping  irregularities  or  new 
growths  from  the  endometrium.  The  shank  should,  as  a  rule,  be 
made  of  flexible  material  such  as  copper. 

Occasionally,  it  is  made  like  a  small  cup,  with  a  sharp  edge,  at- 
tached to  a  long  shank.     Simon's  spoon  is  of  this  description. 

What  are  the  varieties  in  common  use  ? 

Thomas'  wire  loop,  dull  and  flexible. 
Sims'  curette. 
Recamier  curette. 
Simon's  spoon. 

What  is  the  value  of  the  curette  ? 

It  is  a  very  valuable  instrument,  both  for  diagnosis  and  treatment. 
a.  For  diagnosis,   to  scrape  away  some  of  the  contents  of  the 
uterus  for  examination,  to  determine  the  cause  of  hemorrhage. 


THE  CURETTE.  65 

h.  For  treatment,  to  scrape  away  hyperplastic  endometrium, 
villous  growths  or  retained  products  of  conception,  which,  by  their 
vascularity,  easily  cause  hemorrhage. 

In  malignant  disease  of  the  uterus,  the  curette  is  also  of  value  to 
remove  sloughing  masses. 

What  are  the  preliminaries  to  the  use  of  the  curette  ? 

The  patient  should  be  anaesthetized,  placed  in  the  dorsal  position 
on  a  Kelly's  pad,  and  knees  supported  with  a  leg-holder.  The  va- 
gina should  be  scrubbed  with  soap  and  water ;  an  antiseptic  douche 
should  be  given,  and  all  antiseptic  precautions  should  be  observed 
in  regard  to  instruments,  hands,  etc. 

The  perineum  should  be  retracted  with  a  Simon's  or  Sims'  spec- 
ulum ;  cervix  drawn  down  and  steadied  with  a  bullet  forceps,  then 
dilated. 

A  gentle  curettage  can  sometimes  be  performed  without  anaesthe- 
sia, but  for  the  thorough  operation  anaesthesia  is  usually  necessary. 

Describe  briefly  the  method  of  curettage. 

After  dilatation  of  the  cervix,  the  curette  should  be  introduced 
very  gently  until  the  fundus  of  the  uterus  is  reached,  then  with- 
drawn with  the  working  edge  of  the  instrument  pressed  firmly 
against  the  wall  of  the  uterus.  This  process  is  repeated  until  the 
walls  of  the  uterus  feel  smooth.  The  cavity  of  the  uterus  should 
then  be  irrigated  with  an  aseptic  or  antiseptic  solution.  If  necessary 
to  check  hemorrhage,  to  stimulate  contraction,  or  to  maintain  dila- 
tation, a  strip  of  gauze  may  then  be  introduced.  As  a  rule,  gauze 
packing  in  the  uterus  hinders  rather  than  helps  drainage  of  its 
cavity.     The  patient  should  be  confined  to  bed  for  five  to  ten  days. 

When  would  you  prefer  the  dull  to  the  sharp  curette  ? 

When  the  uterus  is  softened  by  pregnancy  or  septic  processes. 
However,  more  depends  on  the  way  the  instrument  is  used  than  its 
sharpness. 

What  are  the  dangers  of  the  curette  ? 

Perforation  of  the  uterus ;  septic  inflammation  of  the  uterus  or 
its  adnexa ;  peritonitis ;  and  induction  of  abortion. 
5 


66  ESSENTIALS  OF  GYNAECOLOGY. 

Drugs  Acting  on  the  Pelvic  Organs. 

Discuss  drugs  having  some  special  action  on  the  pelvic 
organs. 

1.  Iron  is  classed  as  a  tonic  emmenagogue.  It  is  of  use  in 
anaemia  accompanied  by  amenorrhoea. 

2.  Ergot  is  of  undoubted  efficiency  in  causing  uterine  contractions. 
It  is  an  important  abortifacient.  Its  chief  use  is  in  controlling 
uterine  hemorrhage  in  such  conditions  as  subinvolution  and  intra- 
mural fibroids  and  endometritis.  It  often  favors  the  expulsion  of 
moles,  secundines,  or  polypi  from  the  uterus.  It  is  of  no  value  in 
malignant  uterine  tumors,  and  of  no  permanent  value  in  fibroids  in 
checking  their  growth.  In  gynaecology  it  is  given  chiefly  as  the 
fluidextract  (HI  xv-gj)  or  ergotin  (gr.  \-%). 

3.  Hydastis  Canadensis  has  been  relied  on  by  clinicians  to  some 
extent  in  the  same  class  of  cases  in  which  ergot  is  of  value.  It  was 
believed  to  raise  blood  pressure,  and  even' to  have  a  selective  action 
on  uterine  muscle.  Experimental  work  has  recently  shown  that  it 
does  not  raise  pressure.  The  present  verdict  on  all  its  supposed 
virtues  is  not  proved. 

4.  Quinine  seems  to  stimulate  uterine  contractions  during  labor. 
In  malarial  districts  it  has  been  believed  to  be  an  abortifacient,  but 
the  abortions  can  as  well  be  attributed  to  the  malaria  as  to  quinine. 
It  has  been  given  to  normal  women  in  considerable  quantities  for  a 
number  of  days  for  the  purpose  of  producing  abortion  without 
success.  If  a  pregnant  woman  is  known  to  have  malaria,  give  it, 
and  in  curative  quantities,  otherwise  avoid  it  in  pregnancy. 

Savine,  rue,  parsley,  pennyroyal,  and  tincture  of  cantharides  are 
classed  as  stimulating  emmenagogues,  and  have  considerable  popu- 
larity among  the  laity  as  abortifacients.  Their  use  for  this  purpose 
is  quite  dangerous,  since,  if  given  in  sufficient  quantities  to  be 
efficient,  they  are  likely  to  cause  grave  gastro-  intestinal  and  renal 
irritation. 

6.  Cathartics,  especially  the  salines,  are  of  value  in  relieving 
pelvic  congestion.  Clinical  evidence  is  conclusive  that  dysmenor- 
rhoea  is  aggravated  by  constipation,  and  that  a  saline  given  a  day  or 
two  before  the  expected  period  is  among  our  most  valued  means  of 
diminishing  menstrual  pain. 


DRUGS  ACTING  ON  THE  PELVIC   ORGANS.  67 

A  possible  exception  to  the  rule  is  to  be  noted  in  the  case  of  aloes, 
whose  action  is  chiefly  on  the  lower  bowel.  It  is  a  common  constit- 
uent of  abortifacient  mixtures,  and  in  large  doses  may  bring  on  ' '  an 
attack  of  piles,"  hence  the  feeling  that  it  increases  rather  than 
decreases  congestion.  It  is  wiser  to  use  some  other  cathartic  in 
women  with  threatened  abortion. 

7.  Alcohol,  and  especially  gin,  is  a  household  remedy  for 
dysnienorrhoea,  and  undoubtedly  gives  considerable  temporary 
relief.  The  effect  is  partly  due  to  the  flushing  of  the  superficial 
capillaries,  though  blood  pressure  is  not  shown  by  the  sphygmo- 
graph  to  be  changed  by  alcohol  in  small  doses.  Probably  the  effect  is 
more  due  to  the  well-known  ansesthetie  effect  of  alcohol,  to  which  the 
volatile  oil  of  juniper  may  contribute.  Though  efficient  in  relieving 
dysnienorrhoea,  alcohol  and  opium  are  not  to  be  recommended,  as 
the  regular  recurrence  of  the  pain  favors  the  formation  of  a  drug 
habit.  The  coal-tar  antipyretics  effect  dysnienorrhoea  much  as  they 
do  neuralgias,  and  are  to  be  preferred,  if  drugs  are  needed. 

6.  Viburnum. — According  to  clinical  evidence,  this  drug  has  some 
value  in  congestive  dysnienorrhoea.  It  is  wise  to  give  it  a  trial  in 
intractable  cases  of  dysnienorrhoea,  though,  like  other  drugs  recom- 
mended for  the  condition,  it  is  likely  to  prove  disappointing. 

9.  Thyroid  extract,  the  thyroid  gland  of  a  sheep  desiccated  to 
about  one- eighth  of  its  original  weight,  is  of  value  in  some  cases 
of  menorrhagia.  The  cases  where  it  is  of  value  show  other  signs  of 
hypothyroidism,  such  as  obesity  and  dry  skin. 

10.  Ovarian  Extracts. — The  ovary  probably  produces  two  har- 
mones :  a.  One  produced  by  the  corpus  luteum,  whose  action  is 
exerted  on  the  uterus  if  pregnancy  occurs.  It  has  been  shown  in 
animals  that  if  the  corpus  luteum  be  removed  within  six  days  after 
coitus  that  the  ovum  cannot  be  implanted  upon  the  uterine  mucosa. 
b.  A  substance  is  presumably  produced  in  certain  cells  lying  in  the 
ovarian  stroma,  but  originally  derived  from  germinal  epithelium, 
which  is  necessary  to  the  development  of  the  sexual  instinct  and  to 
the  formation  of  secondary  sexual  characters.  In  young  male 
animals  there  are  described  similar  cells  in  the  stroma  of  the  testis 
which  do  not  atrophy  with  the  tubules  when  the  vas  is  tied,  and 
which  are  believed  to  produce  the  testicular  internal  secretion. 
Clinically,  ovarian  extracts  have  been    given  a  trial  with  some 


68  ESSENTIALS  OF  GYNAECOLOGY. 

evidence   that    they   ameliorate   the   nervous  phenomena  of   the 
artificial  but  not  the  natural  menopause. 


Vulvitis. 

What  are  the  varieties  ? 


a.  Occurring    in  both 
children  and  adults  : 


1.  Simple  catarrhal,  acute  or  chronic 

2.  Gonorrhceal ; 

3.  Phlegmonous  ; 

4.  Croupous; 

5.  Gangrenous ; 
b.  Occurring  in  adults  :  Follicular. 


I.  Acute  Simple  Catarrhal  Vulvitis. 

What  are  the  causes  ? 

Lack  of  cleanliness  ; 

Strumous  diathesis  ; 

Discharges  from  cervix,  or  vagina ; 

Injuries  or  friction  from  exercise  ; 

Masturbation  ; 

Awkward,  or  excessive  coitus ; 

Pregnancy ; 

Foreign  bodies ; 

Parasites ; 

Acute  exanthemata ; 

Diabetic  urine. 

What  are  the  symptoms  ? 

General  malaise  ;  some  local  pain  and  burning  ;  parts  are  oedema- 
tous,  congested,  covered  with  a  glairy,  mucous,  excoriating  discharge, 
which  may  extend  to  the  urethra. 

What  is  the  treatment  ? 

Rest  in  bed  ;  warm  sitz-baths ;  lead  and  opium  wash  frequently 
applied  to  the  vulva  ;  lint  soaked  in  it  kept  between  the  labia.  Bis- 
muth, starch,  or  borax  may  with  advantage  be  dusted  on  the  vulva 
in  the  intervals  between  the  applications  of  the  lead  and  opium 
wash.  If  the  vulvitis  is  from  ascarides,  employ  enemata  of  infusion 
of  quassia,  §  ij-Oj. 


vulvitis.  69 

Chronic  Catarrhal  Vulvitis. 

Describe  its  occurrence  and  course. 

Catarrhal  vulvitis  in  children  is  most  apt  to  be  chronic  ;  it  Is  seen 
most  frequently  in  strumous  children,  often  with  no  history  of  the 
acute  stage. 

What  are  the  symptoms  ? 

1.  Discomfort  in  walking  and  in  micturition  ; 

2.  Pruritus ; 

3.  Stains  on  linen. 

What  is  the  treatment  ? 

Build  up  the  constitution  by  tonics  and  fresh  air  ;  observe  cleanli- 
ness ;  if  much  discomfort,  use  lead  and  opium  wash,  followed  later 
by  nitrate  of  silver  (gr.  x-^j)  applied  to  the  vulva  ;  bismuth  .or 
borax  being  dusted  on  between  the  lotions. 

II.  Gonorrhoea  and  Gonorrheal  Vulvitis. 

What  is  the  etiology  ? 

It  is  produced  either  directly  by  intercourse  with  one  who  has 
contracted  gonorrhoea,  or  indirectly  by  soiled  linen,  instruments,  etc. 

What  is  the  diagnostic  value  of  Neisser's  gonococcus,  found 
in  the  discharge  ? 

The  gonococcus  of  Neisser  is  the  sole  cause  of  gonorrhoea,  and  the 
disease  can  only  be  transmitted  through  its  agency. 

Give  an  account  of  the  gonococcus  and  its  inflammations. 

The  gonococcus  is  a  diplococcus  pathogenic  only  for  man.  It  is 
found  in  the  discharges  of  gonorrheal  inflammations  and  is  usually 
contained  in  the  cell  body  of  pus  cells,  but,  as  a  rule,  is  found  be- 
tween rather  than  in  the  epithelial  cells.  It  is  also  found  extra- 
cellular in  the  gonorrhoeal  discharge. 

It  readily  stains  with  the  analin  dyes  but  is  decolorized  by  Gram's 
iodine  solution.  It  grows  best  on  media  containing  human  body 
fluids,  such  as  blood-serum,  various  exudates,  ascitic  and  hydrocele 
fluid,  and  albuminous  urine.  It  is  possible  to  grow  the  organism 
on  animal  fluids,  such  as  dog's  serum.  It  must  be  kept  at  body 
temperature  and  frequently  transplanted. 


70  ESSENTIALS   OF  GYNECOLOGY. 

In  chronic  gonorrhoea  the  germ  is  difficult  to  identify,  and  in 
closed  cavities,  such  as  pyosalpinx  and  Bartholinitis,  it  soon  suc- 
cumbs. On  mucous  surfaces,  as  in  the  cervix  or  deep  urethra  of 
the  male,  it  may  persist  for  years. 

Its  usual  inflammations  are  those  of  the  genital  tract,  but  it  may 
cause  conjunctivitis,  synovitis,  teno-synovitis,  bursitis,  or  malignant 
endocarditis.  The  gonococcus  very  rarely  produces  a  general  peri- 
tonitis. 

The  urinary  tract  is  less  susceptible  to  the  gonococcus  than  the 
genital  with  the  exception  of  the  urethra.  Probably  the  acid  urine 
in  the  bladder  inhibits  its  growth  in  that  organ. 

It  is  rarely  found  associated  with  other  bacteria  in  its  lesions. 
The  female  genital  organs  most  often  the  seat  of  gonorrhoea  are  the 
urethra,  vulvo-vaginal  glands,  cervical  and  corporeal  endometrium, 
and  the  Fallopian  tubes. 

Discuss  latent  gonorrhoea. 

By  this  we  mean  symptomless  gonorrhoea.  The  germs  still  re- 
main and  can  produce  acute  gonorrhoea  with  its  usual  severity  when 
transplanted  to  another  person.  The  subject  of  a  latent  gonorrhoea 
may  at  any  time  light  up  an  attack  as  the  result  of  excesses,  alcoholic 
or  sexual  or  severe  physical  exertions.  The  germs  in  latent  gonor- 
rhoea may  be  few  and  hard  to  find.  They  are  usually  concealed  in 
some  crypt,  gland,  or  fold  of  mucosa.  In  the  female  the  cervix  is  a 
favorite  spot. 

Discuss  immunity  to  gonorrhoea. 

No  one  is  immune  to  the  disease.  Because  of  its  greater  severity 
and  more  rapid  extension  in  some  individuals  it  has  been  inferred 
that  there  may  be  germs  of  differing  virulence.  Predisposing  fac- 
tors, such  as  congestion,  abrasion,  etc.,  are  not  essential,  and  per- 
fectly normal  mucous  membranes  can  be  attacked.  The  nearest 
approach  to  immunity  is  seen  in  the  case  of  two  individuals  having 
frequent  sexual  intercourse  and  having  gonorrhoea  in  the  latent 
form.  Each  has  a  tolerance  to  the  germs  of  the  other,  so  that 
acute  infection  does  not  follow  intercourse  with  each  other.  Either 
is  capable  of  communicating  the  acute  form  to  a  third  person. 

Upon  what  points  would  you  base  a  diagnosis  of  gonorrhoea 
in  the  female? 

Absence  of  history  of  labor,  abortion  or  use  of  instruments,  sud- 


VULVITIS.  71 

den  onset  of  symptoms,  moderate  rise  of  temperature,  as  a  rule, 
without  chill,  yellow  purulent  discharge,  urethritis,  Bartholinitis,  or 
redness  about  the  orifice  of  its  duct.  Any  or  all  of  these  signs  may 
be  present.  The  diagnosis  becomes  positive  when  the  gonococcus 
can  be  identified.  It  is  best  sought  for  in  the  urethral  pus.  Pyo- 
salpinx  is  gonorrhceal  in  a  majority  of  cases. 

What  is  the  differential  diagnosis  between  gonorrhoeal  vul- 
vitis and  acute  simple  catarrhal  vulvitis  ? 
In  gonorrhoeal  vulvitis,  the  onset  is  more  violent ;  more  fever, 
pain,  and  oedema ;  the  inflammation  extends  up  the  vagina,  urethra, 
and  vulvo-vaginal  glands;  pus  can  often  be  pressed  out  of  the 
urethra ;  gonococci  can  be  found  in  the  discharge ;  often  warts  or 
buboes  are  present,  and  sometimes  gonorrhoeal  rheumatism. 

What  is  the  method  of  examining  discharges  for  the  gono- 
coccus ? 

Collect  a  small  drop  of  discharge,  preferably  from  the  urethra, 
Bartholin's  duct,  or  interior  of  the  cervix.  Spread  over  several 
slides  or  cover-glasses.  Stain  one  with  methylin  fluid.  Look  for 
organisms  resembling  the  gonococcus,  note  whether  the  discharge 
is  purulent  and  whether  the  suspected  germs  are  largely  intracellu- 
lar. This  examination  will  often  suffice  if,  as  in  acute  cases,  the 
discharge  is  purulent  and  the  gonococcus  alone  is  seen.  If  the  dis- 
charge is  not  purulent  and  many  varieties  of  bacteria  are  present, the 
case  is  presumably  not  gonorrhoea.  If  any  doubt  exists,  use  Gram's 
stain,  counterstaining  with  Bismarck  brown.  This  will  distinguish 
the  Neisser  from  other  diplococci. 

How  would  you  decide  a  gonorrhoea  has  been  cured? 

The  vaginal  reaction  should  again  become  acid.  Repeated  exami- 
nation of  carefully  selected  specimens  must  fail  to  reveal  the  gonococ- 
cus. If  the  discharge  is  purulent,  but  no  germs  of  any  kind  are 
seen,  still  suspect  the  gonococcus.  When  it  has  disappeared  other 
germs  will  reappear.  Lesions  should  have  disappeared  from  the 
vulva,  and  the  discharge  should  contain  epithelial  rather  than  pus 
cells. 

What  is  the  value  of  gonococcus  anti-serum  and  vaccine? 

With  the  anti-gonococcus  serum   favorable  results   are  claimed 

only  in  the  case  of  the  most  chronic  types  of  the  disease,  such  as 


72  ESSENTIALS   OF   GYNECOLOGY. 

rheumatism.  The  vaccine  is  a  sterilized  culture  of  the  gonococcus. 
A  suspension  of  roughly  100,000,000  germs  is  injected  hypodermically 
as  a  dose.  It  is  too  soon  to  state  results,  but  favorable  reports  have 
been  made  of  its  use  in  joint  complications  and  in  the  vulvo -vagi- 
nitis of  children,  both  acute  and  chronic. 

What  is  the  treatment  of  gonorrheal  vulvitis  ? 

Keep  patient  quiet ;  give  light  diet ;  keep  bowels  open ;  disinfect 
the  parts  with  bichloride  1-5000,  or  lysol  1-100  or  200 ;  then  have 
the  parts  irrigated  every  hour  or  two  with  borax  water  3j-Oj.  If 
discomfort  is  very  great,  lead  and  opium  wash  may  be  frequently 
applied  to  the  vulva,  and  patient  may  take  warm  sitz-baths.  The 
labia  should  be  kept  separated  with  lint  or  gauze.  The  organic 
preparations  of  silver,  such  as  protargol  and  argyrol,  will  be  found  of 
value  applied  to  the  external  genitals  in  the  form  of  watery  solutions 
of  a  strength  of  10  to  25  per  cent. 

If  the  vulvitis  tends  to  become  chronic,  apply  nitrate  of  silver, 
gr.  x-xx-^j. 


III.  Phlegmonous  Vulvitis. 

What  is  the  etiology  ? 

It  may  arise  from  the  following  : — 
Traumatism ; 
Irritating  discharges ; 
Acute  exanthemata ; 
Furunculosis. 

What  are  its  pathology  and  symptoms  ? 

It  is  a  circumscribed  or  diffuse  suppurative  process  manifesting 
itself  by  the  following  symptoms : — 

a.  Subjective  :  Heat  and  pain,  increased  by  standing  or  walking. 

b.  Objective  :    Congestion,  swelling,  induration ;   later,  suppura- 

tion. 

From  what  must  you  differentiate  phlegmonous  vulvitis  ? 

a.  Pudendal  hernia ; 

b.  Dislocated  ovary ; 

c.  Hydrocele  of  round  ligament ; 

d.  Haematoma  of  vulva. 


VULVITIS. 


73 


How  would  you  differentiate  phlegmonous  vulvitis  from  pu- 
dendal hernia  ? 

vs.  Pudendal  Hernia. 


Phlegmonous  Vulvitis 
Signs  of  acute  inflammation. 

Dullness  on  percussion. 
No  impulse  on  coughing. 
Not  reducible. 
History  of  traumatism,  etc. 


None    unless    strangulated,    or 

injured. 
Tympanitic  on  percussion. 
Impulse  on  coughing. 
Usually  reducible. 
History  of  strain. 

How  would  you  differentiate  phlegmonous  vulvitis  from  a 
dislocated  ovary  ? 

Phlegmonous  Vulvitis         vs. 
Signs  of  acute  inflammation. 


Gradual  development. 

No  especial  exacerbation  during 

menstruation. 
No  sense  of  ovarian  compression 

when  pressed  upon. 
Not  the  shape  of  an  ovary. 

How  would  you  differentiate  phlegmonous  vulvitis   from 
hydrocele  of  the  round  ligament  ? 


Dislocated  Ovary. 
Usually  absent. 
Sudden  development. 
Larger  and  more  sensitive  during 

menstruation. 
Peculiar  sensation  when  pressed. 

Has  the  shape  of  an  ovary. 


Phlegmonous  Vulvitis 
Signs  of  acute  inflammation. 
Opaque. 

Never  communicates  with   ab- 
dominal cavity. 


vs. 


Hydrocele  of  Pound  Ligament. 
No  signs  of  acute  inflammation. 
Translucent. 

Sometimes  communicates  with 
abdominal  cavity. 


How  would  you   differentiate  phlegmonous  vulvitis   from 
haematoma  of  vulva  ? 


Phlegmonous  Vulvitis 
Gradual  formation. 
Less    frequent    during    parturi 

tion. 
Color,  red. 
First  hard,  then  soft. 
Less  often  preceded  by  varicosi 

ties. 

What  is  the  treatment  of  phlegmonous  vulvitis  ? 

Tonics:  Arsenic,  quinine,  etc. 


vs.  Hematoma  of  Vulva.  . 

Sudden  onset. 

More  frequent   during  parturi- 
tion. 
Color,  purplish. 
First  soft,  then  hard. 
More  often  preceded  by  varicosi- 
ties. 


74  ESSENTIALS   OF   GYNECOLOGY. 

Wet  antiseptic  dressings,  as  gauze  soaked  in  cool  aluminium 
acetate  solution.  When  pus  has  formed,  open,  drain,  and  dress 
antiseptically. 

IV.  Croupous  Vulvitis. 

Give  the  etiology,  symptoms,  and  treatment. 

A  vulvar  inflammation  with  the  formation  of  a  false  membrane 
may  be  due  to  diphtheria  or  other  infectious  disease,  including 
puerperal  infection.  True  diphtheria  may  appear  first  on  the 
vulva,  the  membrane  resembling  that  of  pharyngeal  diphtheria. 
The  treatment  is  that  of  the  infectious  disease  with  local  use  of 
antiseptics. 

V.  Gangrenous  Vulvitis. 

Give  the  etiology  and  treatment. 

Gangrenous  vulvitis  is  most  frequently  found  complicating  preg- 
nancy, severe  types  of  acute  exanthemata,  and  very  violent  cases  of 
vulvitis  of  other  varieties.  The  disease  known  as  noma  or  cancrum 
oris  is  a  variety  of  gangrene  usually  occurring  about  the  mouth,  but 
it  may  attack  the  genitals  of  children.  The  treatment  consists  of 
constitutional  tonics  and  local  antiseptics. 

VI.  Follicular  Vulvitis. 

Give  the  pathology. 

Follicular  vulvitis  is  an  inflammation  of  the  mucous  and  sebaceous 
glands  and  hair  follicles  of  the  vulva  ;  all  may  be  simultaneously 
affected,  or  one  set  alone  involved. 

What  is  the  etiology  ? 

It  occurs  only  in  adults  ;  any  of  the  causes  of  simple  acute  catarrhal 
vulvitis  may  produce  it ;  among  the  most  common  are  the  follow- 
ing :— 

a.  Lack  of  cleanliness  ; 

b.  Discharges  from  above,  especially  senile  leucorrhoea ; 

c.  Pregnancy ; 

d.  Acute  exanthemata. 

What  are  the  symptoms  ? 

a.  Subjective : — 

Local  heat  and  pain ; 
Pruritus ; 


CYST  AND  ABSCESS   OF  VULVO- VAGINAL  GLAND.  75 

Increased  secretion ; 
Hyperesthesia ; 

Vaginismus  occasionally  present ; 

Vulvar  extremity  of  urethra  is  sometimes  affected,  then  ardor 
urinae  results. 
b.  Objective: — 

The  mucous  membrane  appears  very  red  in  spots,  resembling  the 
papillae  of  the  tongue.  When  the  sebaceous  glands  and  hair  follicles 
are  chiefly  affected,  they  will  be  found  as  little  round  red  papillae,  scat- 
tered over  labia  and  base  of  prepuce  and  clitoris,  not  on  vestibule  ; 
later,  a  drop  of  pus  appears  in  the  apex  of  these  papillae  ;  they  then 
disappear. 

How  would  you  treat  a  case  of  follicular  vulvitis? 

Pay  strict  attention  to  cleanliness ;  during  the  acute  stage  use 
mild  antiseptic  lotions,  as  borax  water  (3j-Oj)  or  alum-acetate  solu- 
tion; later,  apply  nitrate  of  silver  (gr.  x-^j).  Bismuth  or  calomel 
may  be  used  as  a  dusting  powder ;  keep  labia  separated. 


Cyst  and  Abscess  of  Vulvo-vaginal  Gland, 

Cyst  op  Vulvo-vaginal  Gland. 

Give  the  etiology  and  pathology. 

A  cyst  of  the  Bartholinian  or  vulvo-vaginal  gland  is  formed  by  a 
distention  of  the  duct,  or  gland  itself,  caused  by  any  occlusion  of  the 
duct,  especially  from  inflammation,  either  simple  catarrhal  or  gon- 
orrhceal.  A  cyst  of  the  duct  is  more  elongated  than  of  the  gland 
itself ;  a  cyst  of  the  gland  is  occasionally  multiple. 

Abscess  of  the  Vulvo-vaginal  Gland. 

What  is  the  etiology  ? 

The  causes  of  a  vulvitis  may  produce  abscess  of  the  vulvo-vaginal 
gland  ;  gonorrhoea  is  the  most  common  cause. 

What  are  the  symptoms  ? 

Pain  ;  heat ;  swelling  and  redness,  especially  near  orifice  of  duct ; 
it  is  tender  on  pressure  ;  at  first  hard,  later  fluctuating. 


76  ESSENTIALS   OE  GYNECOLOGY. 

How  could  you  differentiate  a  cyst  from  an  abscess  of  the 
vulvo-vaginal  gland  ? 

Cyst  vs.  Abscess. 

Gives  no  signs  of  inflammation.       Shows  inflammation . 
Insensitive  to  pressure.  Sensitive  to  pressure. 

Duration  long.  Duration  shorter. 

What  is  the  treatment  of  a  cyst  of  the  vulvo-vaginal  gland  ? 

The  usual  treatment  is  to  excise  an  elliptical  area  of  mucous  mem- 
brane over  the  sac  on  its  inner  surface  ;  this  exposes  the  sac ; 
now  cut  out  a  large  ellipse  from  it ;  empty  the  sac,  pack  it  with 
iodoform  gauze,  and  apply  an  antiseptic  outside  dressing.   . 

A  better  plan  is  usually  to  dissect  out  the  whole  sac,  if  possible, 
and  bring  together  the  edges  of  the  wound  with  catgut ;  then  apply 
an  antiseptic  dressing  as  before. 

From  what  may  you  get  considerable  hemorrhage  in  extir- 
pating the  sac  ? 

From  the  transversus  perinei  artery,  and  from  the  bulbs  of  the 
vagina. 

How  would  you  treat  an  abscess  of  the  vulvo-vaginal  gland  ? 

Before  the  presence  of  pus  is  detected,  keep  the  patient  quiet  in 
bed ;  apply  soothing  lotions  like  alum-acetate  solution.  As  soon 
as  pus  is  detected,  proceed  as  with  the  cyst  till  sac  is  opened, 
then  with  a  sharp  curette  scrape  the  interior  of  sac  wall ;  irrigate 
with  bichloride  (1-1000);  pack  with  gauze,  and  apply  an  outside 
dressing  of  sterile  gauze,  absorbent  cotton,  and  a  T-bandage. 

From  what  must  you  differentiate  vulvo-vaginal  cyst  or 
abscess  ? 

From  hernia  and  phlegmonous  vulvitis. 

How  would  you  differentiate  vulvo-vaginal  cyst  or  abscess 
from  hernia  ? 

Cyst  or  Abscess  vs.                   Hernia. 

No  impulse  on  coughing.  Impulse  on  coughing. 

Irreducible.  Usually  reducible. 

Dull  on  percussion.  Tympanitic  on  percussion. 

Abscess  shows  signs  of  inflam-  None,   unless    strangulated,   or 

mation.  injured. 

More  circumscribed.  Less  circumscribed. 


PUDENDAL   HEMATOCELE.  77 

How  would  you  differentiate  abscess  of  vulvo-vaginal  gland 
from  phlegmonous  vulvitis  ? 
The  vulvo-vaginal  abscess  is  more  distinctly  circumscribed  and 
globular ;  the  phlegmonous  vulvitis  is  more  diffuse. 


Pudendal  Hernia. 
Describe. 

The  process  of  peritoneum  which  follows  the  round  ligament 

through  the  inguinal  canal  to  its  termination  in  the  labium  majus  ia 

usually  obliterated  at  birth  ;  occasionally  this  obliteration  does  not 

occur,  and  this  channel,  called  the  canal  of  Nuck,  furnishes  a  path 

for  hernia.     The  hernia  may  consist  of  intestine,  omentum,  ovary  01 

bladder.     The  uterus  has  even  been  said  to  follow  this  canal. 

What  are  the  causes  ? 

Blows,  falls,  coughing  or  violent  muscular  exertion. 

What  are  the  symptoms  ? 

The  patient  experiences  a  feeling  of  discomfort,  especially  on 
walking,  and  finds  a  swelling,  which,  if  intestine,  presents  the  fol- 
lowing features :  It  gives  an  impulse  on  coughing ;  is  tympanitic 
on  percussion ;  can  usually  be  reduced,  and,  unless  strangulated, 
or  injured,  presents  no  signs  of  inflammation. 

If  the  hernia  consists  of  an  ovary,  it  gives  the  ovarian  sensation 
on  pressure,  and  its  size  and  tenderness  are  both  increased  during 
menstruation. 

What  is  the  treatment  ? 

Place  patient  on  her  back,  with  knees  elevated  ;  reduce  by  gentle 
taxis,  if  possible,  and  apply  a  suitable  truss.  If  strangulation  has 
occurred,  a  surgical  operation  is  necessary.  If  the  hernia  consists 
of  an  ovaiy  which  has  become  adherent,  protect  it  from  pressure  by 
a  hollow  pad,  or  if  it  occasions  great  distress,  remove  it. 

Pudendal  Hematocele. 

What  are  the  synonyms  ? 
Hseinatoma  or  thrombus  of  vulva. 


78  ESSENTIALS   OF  GYNAECOLOGY. 

Define. 

Pudendal  hematocele  (better  hsematoma)  consist  of  an  effusion 
of  blood  into  the  tissue  of  the  vulvo-vaginal  region,  usually  into  one 
labium,  or  into  the  areolar  tissue  surrounding  the  vaginal  walls. 

What  is  the  etiology? 

Pudendal  haematocele  is  predisposed  to  by  any  condition  causing, 
or  accompanied  by,  a  dilatation  of  the  vessels  of  the  vulva : — 

Pregnancy ; 
Tumors ; 
Varicocele ; 
Labor. 
The  exciting  causes  are  blows,  falls,  muscular  efforts,  etc. 

Describe  the  symptoms  and  course. 

The  patient  experiences  pain  of  a  tearing  character,  which,  if  the 
effusion  is  large,  may  be  accompanied  by  faintness.  Sometimes  the 
effusion  presses  on  the  urethra  and  causes  difficulty  in  micturition. 
The  swelling  is  at  first  soft ;  later,  hard. 

If  small,  it  is  usually  absorbed  ;  it  sometimes  remains  for  a  long 
time ;  sometimes  suppurates. 

How  would  you  differentiate   pudendal  hematocele  from 
hernia  ? 

Pudendal  Hcematocele  vs.                   Hernia. 

History.  History. 

No  impulse  on  coughing.  Impulse  on  coughing. 

Dull  on  percussion.  Tympanitic. 

Irreducible.  Usually  reducible. 

First  soft,  then  hard.  More  uniform. 

How  would  you  treat  a  case  of  pudendal  hematocele  ? 

While  effusion  is  in  progress,  apply  ice  and  pressure.  If  the 
effusion  is  large,  occurs  during  labor  and  obstructs  the  passage  of  the 
head,  incise,  turn  out  the  clots  and  pack  with  iodoform  gauze.  If 
the  effusion  is  small,  apply  soothing  lotions  like  alum-acetate  solution ; 
if  suppuration  occurs  or  if  absorption  is  long  delayed,  incise,  irrigate 
with  an  antiseptic  solution,  and  pack  with  iodoform  gauze. 


ERYTHEMA  OE  THE  VULVA.  79 

Hemorrhage  from  Vulva. 

What  is  the  etiology  ? 

The  predisposing  causes  are  the  same  as  for  pudendal  hemato- 
cele and  hematocele  itself.   The  existing  causes  are  the  following  : — 

Violent  muscular  efforts ; 

Blows  ; 

Punctures  or  lacerations. 

What  is  the  treatment  ? 

If  it  is  a  ruptured  hematocele,  incise,  turn  out  the  clots  and  pack  ; 
otherwise,  catch  bleeding  points  and  ligature,  or  apply  pressure, 
assisted  by  a  tampon  in  the  vagina. 


Skin  Diseases  Affecting  the  Vulva. 

What  are  the  most  common? 

Erythema,  eczema,  and  herpes  are  most  frequently  seen  ;  eczema 
may  be  acute  or  chronic. 

Erythema  of  the  Vulva. 

Give  the  etiology,  symptoms  and  treatment. 

Etiology. — Erythema  is  most  apt  to  occur  in  fleshy  people,  espe- 
cially in  hot  weather.     The  exciting  causes  are  : — 

Lack  of  cleanliness ; 
Irritating  discharges  ; 
Exercise. 

Symptoms. — The  parts  become  red,  sensitive,  often  excoriated  and 
painful,  especially  in  walking. 
Treatment. — Cleanliness ; 

Attention  to  bladder  and  urine ; 
Desiccating  powders,  such  as  bismuth  subnitrate, 
oxide  of  zinc,  or  calomel. 


80  ESSENTIALS   OE   GYNECOLOGY. 


Eczema  of  the  Vulva. 

Give  the  etiology. 

Eczema  is  predisposed  to  by  functional  disturbance  of  the  gastro- 
intestinal tract,  gout  or  rheumatism  ;  it  is  especially  apt  to  occur  in 
women  near  the  menopause.  The  most  frequent  exciting  cause  is 
an  irritating  discharge  from  the  cervix  or  vagina. 

What  are  the  symptoms  ? 

The  disease  may  be  acute  or  chronic.  In  the  acute  form,  the  parts 
become  reddened  and  edematous  ;  vesicles  appear,  break  and  dis- 
charge a  thick,  tenacious  fluid,  which  forms  crusts.  The  subjective 
symptoms  are  severe  burning  and  itching. 

In  the  chronic  form,  the  parts  become  thickened  and  scaly ;  the 
subjective  symptoms  resemble  those  of  the  acute,  but  are  a  little 
less  marked. 

What  is  the  treatment  ? 

In  the  acute  form,  observe  strict  cleanliness  ;  if  the  burning  is  very 
severe,  use  alkaline  sitz-baths  and  sedative  lotions ;  later,  or  at  first 
if  burning  and  itching  are  not  intense,  an  ointment  like  the  follow- 
ing is  very  good  :  — 

R.    Acidi  salicylici,.  . gr.  xv, 

Zincioxidi, ^ij  ss, 

Pulv.  amyli, 3  jj  ss, 

Petrolati, ^j. 

M.    Sig. — Apply  locally. 

In  the  chronic  form,  use  the  same  treatment  during  the  exacerba- 
tions as  for  the  acute  ;  later,  an  ointment  containing  oil  of  cade  will 
be  found  of  value. 

What  are  the  most  common  parasites  found  on  the  vulva  ? 

The  pediculus  pubis,  or  crab  louse,  is  the  parasite  most  often  found 
infecting  the  vulva. 

The  acarus  scabiei,  or  itch  mite,  is  occasionally,  but  rarely,  found 
on  the  vulva  as  part  of  a  general  infection. 

Give  the  etiology,  symptoms  and  treatment  of  infection  with 
pediculi  pubis. 

Etiology.— The  pediculus  pubis  is  almost  always  conveyed  directly 
from  person  to  person,  usually  in  sexual  intercourse. 


NEW  GROWTHS   OF  THE  VULVA.  81 

Symptoms. — There  is  burning  and  itching;  often  an  eruption 
resembling  eczema.  The  diagnosis  is  made  by  finding  the  pediculus 
closely  adherent  to  the  roots  of  the  hair. 

Treatment.  — Any  one  of  the  following  : — 

Corrosive  sublimate,  1-1000 ; 
Tincture  of  delphinium  ; 
Carbolic  5  per  cent,  solution. 

It  is  often  best  to  shave  the  pubes  before  applying  the  lotion  or 
ointment. 

Give  the  etiology,  symptoms  and  treatment  of  scabies  of  the 
vulva. 

Etiology. — The  acarus  scabiei  is  rarely  found  on  the  vulva,  but 
this  occasionally  occurs  as  part  of  a  general  infection. 

Symptoms. — There  is  an  intense  pruritus,  worse  when  the  body  is 
warm.  The  diagnosis  is  made  by  finding  the  burrows  on  other  parts 
of  the  body,  especially  between  the  fingers. 

Treatment. — A  warm  soap  and  water  bath,  followed  by  an  oint- 
ment composed  of  sulphur  alone,  or  combined  with  balsam  of  Peru. 

Discuss  herpes  of  the  vulva. 

This  disease  occasionally  involves  the  parts  about  the  vulva  as  it 
does  the  mouth.  Sometimes  it  is  unilateral  and  affects  the  area 
supplied  by  a  single  nerve. 

The  diagnosis  is  made  by  the  appearance  of  more  or  less  pain  in 
the  region,  followed  in  a  short  time  by  the  characteristic  vesicles. 
When  occurring  over  the  distribution  of  a  single  nerve,  it  is  more 
accurately  spoken  of  as  zoster. 

Treatment. — While  the  vesicles  are  appearing,  a  wet  dressing  of 
aluminium  acetate  will  give  relief.  Afterward  apply  an  ointment 
of  menthol  or  a  dusting  powder.  Allow  the  vesicles  to  dry  up 
rather  than  open  them. 

New  Growths  of  the  Vulva. 

Mention  the  principal  new  growths  occurring  on  the  vulva? 
a.  Papillomata — 

1.  Simple ; 

2.  Pointed  condylomata ; 

3.  Syphilitic  condylomata. 
6 


82  ESSENTIALS   OF   GYNAECOLOGY. 

u.  Cyst  of  vulvo-vaginal  gland. 

c.  Carcinoma. 

d.  Sarcoma. 

e.  Elephantiasis. 
/  Fibromata. 

g.  Lipomata. 
h.  Neuromata. 
i.  Lupus. 

Discuss  adherent  prepuce 

In  children  the  prepuce  is  often  found  adherent  to  the  clitoris, 
and  in  most  cases  gives  rise  to  no  symptoms.  In  some,  however,  there, 
as  in  the  male,  retained  smegma  and  consequent  irritation  of  the 
parts  lead  to  such  symptoms  as  itching,  rubbing,  masturbation,  and 
enuresis.  When  symptoms  are  present,  separate  the  adhesions  or, 
better  still,  to  avoid  their  reforming,  amputate  the  prepuce. 

Simple  Papillomata. 

What  is  the  etiology  and  treatment? 

Etiology. — A  simple  papilloma,  or  wart,  occurs  rarely  on  the 
vulva  ;  it  is  usually  congenital  and  of  little  importance. 

Treatment. — It  may  be  destroyed  with  nitric  acid,  or  it  may  be 
excised  under  cocaine,  and  the  wound  closed  with  fine  sutures. 


Pointed  Condylomata. 

What  is  the  etiology  and  appearance  ? 

Pointed  condylomata,  or  gonorrhoeal  warts,  as  they  are  commonly 
called,  are  due  to  acrid  macerating  discharges  on  the  vulva,  usually 
but  not  necessarily  gonorrhoeal;  they  are  always  multiple,  and 
occur  most  frequently  on  the  inner  surfaces  of  the  labia  majora,  on 
the  perineum  and  about  the  anus ;  they  are  of  a  grayish  color  and 
often  pediculated ;  their  summit  is  divided  into  pointed  lobules. 
When  on  the  skin,  they  are  sometimes  dry  and  hard  ;  on  a  mucous 
surface  they  are  soft.  The  congestion  of  the  vulva  accompanying 
pregnancy  predisposes  to  them,  and  they  are  then,  as  in  other  cases, 
frequently  but  not  necessarily  gonorrhoeal. 
What  is  the  treatment  of  pointed  condylomata  ? 

Treat  the  discharge  and  keep  the  parts  clean  by  frequent  wash- 


SYPHILITIC   CONDYLOMATA.  83 

ing.  Then  dry  and  dust  with  powder,  such  as  calomel  and  starch, 
and  keep  adjacent  surfaces  apart  with  gauze  or  cotton  between 
the  labia.  If  this  does  not  suffice,  cut  them  off  with  knife  or  scis- 
sors and  touch  the  base  with  a  caustic ;  under  cocaine  this  may  be 
made  practically  painless.  Pedunculated  ones  may  be  removed 
bloodlessly  by  tying  a  silk  thread  about  the  base.  They  will  then 
drop  off  in  a  few  days. 


Syphilitic  Condylomata. 

What  is  the  etiology,  appearance  and  treatment  ? 

Syphilitic  condylomata,  or  mucous  patches,  are  the  result  of  the 
syphilitic  poison.  They  are  broad  and  flat,  situated  most  frequently 
on  the  inner  surface  of  the  labia  majora,  and  usually  covered  with  a 
grayish,  mucus-like  secretion.  According  to  Duhring,  they  some- 
times take  on  a  more  warty  growth. 
Treatment. — Cleanliness ; 

Calomel  locally ; 

Constitutional  treatment  for  syphilis. 

Discuss  syphilitic  chancre  in  women. 

The  typical  Hunterian  chancre  is  infrequently  seen  on  the  vulva. 
Mixed  infection  leads  to  a  more  or  less  ulcerated  lesion.  Multiple 
chancre  is  more  common  than  with  men.  It  is  often  small  and  evanes- 
cent, consequently  secondary  symptoms  are  frequently  the  first  to 
attract  attention,  and  then  the  chancre  may  have  largely  disappeared. 
Chancres  are  most  often  found  on  the  labium  majus,  less  often  on 
the  labium  minus  and  fourchette.  In  some  cases  the  sore  is  small, 
but  there  is  an  area  of  indurative  oedema  widely  transcending  the 
limits  of  the  sore.  Chancre  occurs  infrequently  on  the  cervix.  It 
is  said  to  disappear  before  the  secondary  manifestations. 

Discuss  tertiary  syphilis  of  the  vulva. 

This  may  lead  to  extensive  loss  of  substance  with  deep  and  chronic 
ulcers,  which  later  cicatrize.  Rectal  and  urethral  fistulse  occur.  In 
the  vicinity  of  the  ulcer  there  is  usually  an  area  of  indurative 
oedema  resembling  elephantiasis.  Elephantiasis  is  by  many  thought 
to  be  syphilitic  when  occurring  on  the  vulva.  Do  not  rule  out 
syphilis  of  the  vulva  simply  because  you  find  no  signs  of  the  disease 
elsewhere, 


84  ESSENTIALS   OF   GYNECOLOGY. 

Pruritus  Vulvae. 

Define. 

Pruritus  vulvas,  a  symptom  rather  than  a  disease  per  se,  consists 
of  an  irritation  of  the  nerves  of  the  vulva,  accompanied  by  intense 
itching,  at  first  localized,  later  extending,  from  the  mechanical  irrita- 
tion of  scratching. 

What  is  the  etiology  ? 

The  predisposing  causes  are  : — 

a.  Poor  health. 

b.  Disorders  of  the  digestive  tract. 

c.  Anything  producing  congestion  of  the  vulva,  such  as— 

Pregnancy ; 

Tumors  in  neighborhood ; 

Diseases  of  uterus  or  appendages ; 

Menopause. 

d.  Lack  of  cleanliness. 

The  exciting  causes  are  chiefly  the  following : — 

1.  Irritating  discharges  from  cervix,  vagina,  urethra  or  vulva. 

2.  Diabetic  urine.  — „ 

3.  Eruptions. 

4.  Parasites. 

5.  Masturbation. 

6.  Yegetations  on  vulva. 

7.  Kraurosis  vulvae.  This  is  an  atrophic  condition  of  the  vulva. 
It  is  thought  to  be  an  atrophic  stage  of  long-continued  inflammation 
of  the  parts.  It  begins  about  the  clitoris,  and  chiefly  involves  cli- 
toris, vestibule,  and  labia  minora.  There  is  an  increase  of  fibrous 
tissue  in  the  mucous  membrane,  with  a  disappearance  of  its  papillae, 
giving  the  parts  a  smooth  white  appearance.  It  usually  causes  an 
intense  itching  and  hyperaesthesia ;  other  cases  are  painless. 

What  are  the  symptoms  ? 

An  intense  itching,  at  first  only  at  intervals  after  active  exercise, 
over-indulgence  at  the  table,  lying  in  a  warm  bed,  or  sexual  inter- 
course. Later,  the  itching  becomes  constant ;  the  desire  to  scratch 
becomes  irresistible,  causing  the  patient  to  avoid  society ;  it  some- 
times leads  to  nervous  depression  and  melancholia. 


HYPERESTHESIA   OF  THE  VULVA.  85 

What  is  the  treatment  ? 

First  ascertain  the  cause,  if  possible. 

Build  up  the  general  health. 

Regulate  the  diet. 

Observe  strict  cleanliness. 

Destroy  parasites  if  present. 

Treat  diabetes  if  present. 

Treat  eruptions. 

If  there  is  an  acid  discharge  from  above,  tampon  vagina. 

Let  patient  use  frequent  warm  sitz-baths. 

Apply  any  one  of  the  following  : — 

Hot  lead  and  opium  wash  ; 

Carbolic  solution,  2-3  per  cent. ; 

Bismuth  or  calomel  dusted  on  vulva , 

Nitrate  of  silver  (gr.  x-Jj) ; 

Cocaine,  4  per  cent,  solution ; 

An  ointment  containing  oxide  of  zinc  and  oil  of  cade. 

Hyperesthesia  of  the  Vulva. 

Describe. 

This  consists  of  an  excessive  sensibility  of  the  nerves  supplying  the 
mucous  membrane  of  some  portion  of  the  vulva. 

What  is  the  etiology  ? 

The  menopause  seems  to  predispose  to  it ;  also  the  hysterical  and 
melancholic  state.  An  irritable  urethral  caruncle  sometimes  acts  as 
an  exciting  cause.  A  peculiar  atrophic  condition  of  the  skin  of 
nymphae  and  vestibule,  called  kraurosis  vulvae,  is  an  occasional  cause. 
Often  no  cause  can  be  assigned. 

What  are  the  symptoms  ? 

Hyperesthesia,  especially  about  the  vestibule  and  labia  minora  ; 
there  is  no  pruritus,  and  signs  of  inflammation  are  absent  except 
occasional  erythematous  spots ;  dyspareunia  is  very  marked ;  the 
slightest  friction  causes  pain. 

What  is  the  treatment  ? 

Build  up  the  constitution  with  tonics,  change  of  air,  etc. 
Interdict  sexual  intercourse. 


86  ESSENTIALS   OF   GYNECOLOGY. 

Administer  the  bromides  internally. 
Externally  apply  one  of  the  following  : — 

Carbolic  lotion,  2-3  per  cent ; 

Nitrate  of  silver  solution  (gr.  x-xx-^j) ; 

Lead  and  opium  wash  ; 

Four  per  cent,  solution  of  cocaine. 

Vaginismus. 

Define. 

Sims  defined  vaginismus  as  ' '  an  excessive  hyperesthesia  of  the 
hymen  and  vulvar  outlet,  associated  with  such  involuntary  spasmodic 
contraction  of  the  sphincter  vaginae  muscle  as  to  prevent  coitus. ' ' 

What  is  the  pathology? 

There  are  usually  found  sensitive  papillae  about  the  base  of  the 
hymen  ;  an  hypertrophy  of  the  papillae  and  connective  tissue  of  the 
hymen  ;  occasionally  the  lesion  seems  to  be  at  a  distance,  as  in  the 
uterus  or  appendages  ;  sometimes  no  lesion  is  visible. 

What  is  the  etiology? 

The  predisposing  causes  are — 

1.  A  narrow  vagina. 

2.  A  dense,  thick  hymen. 

3.  Malposition  of  the  vulva. 
The  exciting  causes  are — 

1 .  Disturbances  of  the  sexual  function. 

2.  Masturbation. 

3.  Inability  of  the  male  to  complete  the  sexual  act. 
It  usually  occurs  in  the  newly  married. 

What  is  the  treatment  ? 

Palliative. — Interdict  efforts  at  coitus  for  a  time.  Forcibly  di- 
late the  hymen,  under  anaesthesia,  by  inserting  and  separating  the 
thumbs  ;  then  insert  one  of  Sims'  glass  vaginal  plugs. 

Radical. — Excise  the  hymen  and  insert  one  of  Sims'  plugs. 

Coccygodynia. 

Define  and  give  the  etiology. 

Coccygodynia,  or  coccyodynia,  is  a  "painful  affection  of  the  mus- 
cles, tendons,  and  nerves  of  the  coccyx,  with  or  without  disease  of 
the  bone  itself. "     (Mann). 


IRRITABLE   URETHRAL   CARUNCLE.  «7 

It  occurs  most  frequently  after  childbirth,  but  is  also  produced  by 
mechanical  causes,  such  as  blows,  falls,  kicks,  etc.  Among  other 
causes  are  disease  of  the  pelvic  organs,  rheumatism  and  gout.  Hys- 
teria largely  predisposes  to  it ;  in  some  cases  no  cause  can  be  assigned. 

What  are  the  symptoms  ? 

Pain  in  the  coccygeal  region,  increased  by  motion  bringing  into 
play  the  muscles  attached  to  the  coccyx ;  especially  rising  after  sit- 
ting, defecation,  coitus,  sometimes  even  walking. 

Pressure  on  the  coccyx  elicits  the  characteristic  pain. 

The  condition  must  be  differentiated  from  disease  of  the  rectum 
or  anus,  and  from  pure  hysteria. 

What  is  the  treatment  ? 

First  attend  to  the  general  condition,  rheumatism,  hysteria,  etc., 
if  this  fails,  we  have  two  operations  : — 

1.  Cutting  the  attachments  of  the  muscles  to  the  coccyx. 

2.  Extirpation  of  the  coccyx. 

Neither  operation  is  attended  with  any  great  success. 


Irritable  Urethral  Caruncle. 

Define. 

An  irritable  urethral  caruncle  is  a  deep  red  mass,  veiy  vascular 
and  sensitive,  situated  at  the  mouth  of  the  urethra,  or  just  within 
the  canal ;  it  consists,  according  to  Hart  and  Barbour,  of  dilated  capil- 
laries in  connective  tissue,  the  whole  being  covered  with  squamous 
epithelium. 

What  is  the  etiology  ? 

But  little  is  known  of  its  etiology ;  it  occurs  at  all  ages,  and  in 
both  married  and  single  women. 

What  are  the  symptoms  ? 

The  patient  complains  of  frequent  and  painful  micturition  ;  later, 
this  dysuria  increases,  and  pain  is  caused  by  walking,  pressure  or 
friction  of  any  kind.  Intercourse  causes  both  pain  and  hemorrhage. 
The  nervous  symptoms  are  well-marked  ;  hysteria,  melancholia,  etc. 

On  examination,  one  finds  a  raspberry-looking  mass  at  the  meatus  ; 
it  is  very  sensitive  and  bleeds  easily  ;  it  may  be  single  or  multiple. 


88  ESSENTIALS   OF   GYNECOLOGY. 

From  what  must  you   differentiate   an   irritable  urethral 
caruncle,  and  how  ? 

From  polypi,  venereal  warts  and  prolapse  of  the  urethral  mucous 
membrane. 

Polypi  are  usually  higher  in  the  urethra,  are  less  vascular  and 
less  sensitive. 

Venereal  warts  are  less  vascular,  insensitive,  and  usually  accom- 
panied by  others.     The  history  may  aid. 

Prolapse  of  the  urethral  mucous  membrane  may  resemble  a 
caruncle  in  appearance,  but  it  usually  surrounds  the  meatus  more,  is 
less  vascular  and  less  sensitive,  is  continuous  with  the  urethral 
mucous  membrane,  and  can  usually  be  reduced. 

What  is  the  treatment  ? 

Employ  anaesthesia  ;  cut  off  the  caruncle  and  touch  the  base  with 
nitric  acid  or  the  actual  cautery.     You  may  ligate  before  cutting. 

What  is  the  prognosis  ? 

If  the  growth  is  single  and  near  the  meatus,  the  prognosis  is  good ; 
if  multiple  and  extending  up  the  urethra,  they  may  recur. 

Prolapse  of  the  Urethral  Mucous  Membrane. 

Describe. 

Prolapse  of  the  urethral  mucous  membrane  may  involve  the  whole 
circumference  of  the  meatus,  or  only  a  portion  ;  if  the  latter,  it  is 
the  lower  portion  which  is  usually  affected  ;  a  slight  redundancy  at 
the  meatus  is  common  ;  a  prolapse  sufficient  to  form  a  tumor  is  rare. 
At  first  the  exposed  mucous  membrane  is  of  its  normal  pink  color  ; 
later  it  assumes  an  angry  red  color,  often  becomes  excoriated  and 
sensitive  ;  urethritis  and  cystitis  may  accompany  it. 

What  is  the  etiology  ? 

Frequent  child-bearing,  dilatation  of  the  urethra  and  a  lax  condi- 
tion of  the  tissue,  from  whatever  cause,  undoubtedly  predispose  to 
prolapse  of  the  urethral  mucous  membrane.  The  exciting  causes 
are  usually  vesical  and  rectal  irritation,  accompanied  by  straining. 

What  are  the  symptoms  ? 

Frequent  micturition,  which  soon  becomes  painful,  tenesmus,  and 
if  vesical  tenesmus  previously  existed,  it  becomes  much  aggravated. 


DISEASES  OF  THE  VAGINA.  89 

What  is  the  treatment  ? 

If  the  prolapse  is  recent,  an  attempt  at  cure  may  be  made  by 
reducing  the  mucous  membrane,  keeping  the  patient  quiet  in  bed, 
making  astringent  applications  to  the  urethra  and  removing  the 
cause  of  previous  vesical  or  rectal  tenesmus,  if  present. 

If  these  procedures  fail,  remove  the  prolapsed  portion  by  one  of 
the  following  methods: — 1.  If  small,  ligate  and  excise;  if  more 
extensive,  excise  the  redundancy  and  stitch  mucous  membrane  of 
urethra  to  the  border  of  the  meatus.  2.'  Emmet's  "button-hole  " 
operation.     The  first  method  is  usually  the  preferable  one. 

Malformations  of  the  Vulva. 

What  are  the  principal  malformations  of  the  vulva  ? 

1.  Absence  of  the  vulva. 

2.  Hypospadias,  in  which  the  posterior  wall  of  the  urethra  is 
defective. 

3.  Epispadias,  in  which  the  anterior  urethral  wall  is  defective, 
usually  combined  with  a  defect  in  the  anterior  wall  of  the  bladder. 

4.  The  clitoris  may  be  absent,  rudimentary,  or  hypertrophied. 

5.  The  labia  minora  may  be  absent,  rudimentary,  or  greatly  hyper- 
trophied, as  in  the  "  Hottentot  apron." 

6.  Less  often  the  labia  majora  may  be  hypertrophied. 

7.  No  well  attested  case  of  true  hermaphrodism,  i.  e.,  an  indi- 
vidual with  both  ovary  and  testicle,  has  ever  been  reported.  True 
hermaphrodism  is  common  in  animals  below  the  vertebrates. 

8.  Pseudo-hermaphrodism.  This  is  spoken  of  as  male  or  female 
pseudo-hermaphrodism,  depending  on  whether  ovaries  or  testes  are 
present.  There  will  be  accessory  sexual  characters  of  the  opposite 
sex  ;  thus  a  male  may  have  a  vagina  and  rarely  a  uterus.  Most  of 
the  individuals  are  essentially  males  with  deficiency  of  development  of 
the  external  genitals,  soprano  voice,  and  little  hair  on  face  or  genitals. 

Diseases  of  the  Vagina. 

Discuss  the  relation  of  the  normal  vagina  to  bacteria. 

The  vagina  normally  contains  a  number  of  bacterial  species  which 
affect  an  entrance  into  it  soon  after  birth.     None  of  these  bacteria 


90  ESSENTIALS   OF   GYNECOLOGY. 

are  pathogenic.  If  pathogenic  ones  other  than  the  gonococcus  are 
introduced  into  the  vagina  they  disappear  in  a  few  days,  or  if  they 
remain  longer  their  virulence  is  diminished.  A  number  of  factors 
contribute  to  this  result,  the  chief  being  the  acid  reaction  and  an- 
aerobic condition  of  the  vagina  and  the  bactericidal  power  of  the 
serum  of  its  secretion.  The  last  is  of  the  most  importance.  Kronig 
showed  that  the  normal  secretion  when  removed  from  the  vagina 
was  a  poor  culture  medium  for  pathogenic  germs,  but  became  a 
good  culture  medium  when  heated  to  the  coagulating  temperature 
for  blood  serum. 

What  are  the  varieties  of  inflammation  of  the  vagina  ? 

1.  Simple  catarrhal  vaginitis,  or  colpitis. 

2.  Gronorrhoeal. 

3.  Ulcerative,  senile  or  adhesive. 

4.  Croupous. 

Simple  Catarrhal  Vaginitis. 

What  is  the  etiology  ? 

The  predisposing  causes  are— 

a.  General  bad  health. 

b.  Anything  causing  local  congestion,  as — 

Disease  of  heart  or  lungs  ; 
Disease  of  the  pelvic  organs ; 
Pregnancy. 
The  exciting  causes  are  : — 

a.  Irritating  discharges  from  the  cervix. 

b.  The  use  of  too  hot,  too  cold  or  irritating  douches. 

c.  Awkward  or  excessive  coitus. 

d.  Foreign  bodies,  as  pessaries,  tampons,  etc. 

What  are  the  symptoms  ? 

Simple  catarrhal  vaginitis  may  be  acute  or  chronic. 

The  subjective  symptoms  of  the  acute  are  a  feeling  of  heat  in  the 
vagina,  pain  in  the  pelvis,  and  sometimes  vesical  and  rectal  irrita- 
bility. 

The  objective  symptoms  are  a  muco-purulent  vaginal  discharge 
which  may  irritate  the  vulva ;  the  vagina  appears  red,  perhaps  gran- 
ular  or  cystic  in  places. 


GONORRHCEAL  VAGINITIS.  91 

The  chronic  form  resembles  the  acute  except  in  degree ;  in  it  the 
subjective  symptoms,  save  itching  caused  by  the  leucorrhoea,  are 
usually  absent. 

What  is  the  treatment  of  simple  catarrhal  vaginitis  ? 

In  the  early  stages,  keep  the  patient  quiet ;  keep  the  bowels  open, 
and  give  light  diet ;  keep  the  urine  bland  by  alkaline  diluents.  If 
the  itching  is  severe,  let  the  patient  take  frequent  warm  alkaline 
sitz-baths ;  in  addition,  irrigation  of  the  vagina  with  warm  water 
containing  either  of  the  following  will  be  found  of  value :  Liquor 
plumbi  subacet.  3j-Oj ;  borax  3j-Oj. 

After  irrigation  it  is  well  to  dust  some  desiccating  powder,  like 
bismuth,  upon  the  vulva. 

When  the  vaginitis  becomes  subacute  or  chronic,  make  applica- 
tion to  the  vagina  of  nitrate  of  silver  gr.  x-xxx-^j,  or  pyroligneous 
acid. 

Let  the  patient  use  daily  vaginal  douches  of  hot  water  containing 
borax,  3j-Oj ;  or  sulphate  of  zinc,  3ss-3j-Oj ;  or  alum,  3j-Oj. 

The  douches  should  be  taken  while  the  patient  is  in  the  dorsal 
position,  not  sitting. 


Gonorrhoeal  Vaginitis. 

What  is  the  frequency  of  gonorrhoeal  vaginitis  ? 

This  variety  of  vaginitis  is  quite  uncommon  in  adults.  The 
vagina  escapes  acute  inflammation  even  when  the  cervix  and  vulva 
are  involved.  This  is  due  to  the  absence  of  glands  in  the  vagina 
and  its  skin-like  character.  The  case  is  different  with  children, 
the  vagina  in  them  being  a  favorite  spot  for  infection.  Owing  to 
the  many  folds  in  the  child's  vagina  and  the  narrow  opening  in  the 
hymen  it  is  particularly  hard  to  treat. 

How  does  gonorrhoeal  vaginitis  differ  from  the  simple  catar- 
rhal? 

a.  The  onset  is  usually  more  acute. 

b.  The  discharge  is  more  purulent,  viscid  and  offensive  than  in 
the  simple  catarrhal. 

c.  Urethritis  is  more  common. 


92  ESSENTIALS  OF  GYNAECOLOGY. 

d.  Sometimes  a  history  of  exposure  to  infection  can  be  obtained. 

e.  Often  gonorrheal  warts  or  buboes  are  present. 

/  The  most  certain  diagnostic  point  is  the  presence  of  gonococci. 

What  are  the  frequent  complications  and  results  of  gonor- 
rheal vaginitis  ? 

Vulvitis,  urethritis,  endometritis,  salpingitis,  ovaritis  and  perito- 
nitis. 

The  dangers  of  gonorrhoeal  vaginitis  have  been  greatly  under- 
estimated. 

What  is  the  treatment  of  gonorrhoeal  vaginitis  ? 

Keep  the  patient  quiet ;  attend  to  diet ;  move  the  bowels  with 
salines ;  keep  urine  bland.  During  the  acute  stage,  let  the  patient 
have  bichloride  vaginal  douches,  1-10,000,  three  or  four  times  a  day. 
After  the  acute  stage  has  passed,  thoroughly  disinfect  the  vagina 
with  bichloride,  1-1000,  and  loosely  pack  the  vagina  with  sterile 
gauze  to  keep  the  walls  separated  and  the  labia  apart,  thus  insuring 
drainage.  Repeat  this  process  every  24  hours  until  the  disease  has 
subsided. 

If  the  condition  tends  to  become  chronic,  apply  nitrate  of  silver, 
gr.  xx-xxx-^j,  two  or  three  times  a  week,  letting  the  patient  use 
daily  douches  of  borax  water. 

The  most  feasible  method  of  treating  the  condition  in  children  is 
by  means  of  suppositories  of  gelatine  and  glycerine  impregnated 
with  protargol  or  argyrol.  These  are  easily  inserted,  and  on  melting 
the  medication  readily  reaches  all  parts  of  the  vagina. 


Ulcerative  Vaginitis. 
Describe. 

Ulcerative,  senile  or  adhesive  vaginitis  is  present  to  a  greater  or 
less  extent  in  nearly  every  woman  over  60.  It  may  occur  earlier  in 
life. 

There  is  a  desquamation  of  the  squamous  epithelium  in  spots, 
and  where  these  raw  areas  lie  in  apposition,  adhesion  is  apt 
to  occur.     There  is  usually  a  thin  leucorrhoea,  which  irritates  the 


PELVIC   PERITONEUM.  93 

vulva  and  causes  pruritus.  Hemorrhages  are  frequent,  espe- 
cially after  examinations  or  intercourse.  The  bleeding  is  not 
likely  to  be  so  severe  as  in  cases  of  carcinoma  of  uterus  and 
vagina. 

What  is  the  treatment  ? 

The  treatment  consists  in  the  application  to  the  vagina  of  such 
solutions  as  nitrate  of  silver,  gr.  x-xx-^j,  or  pyroligneous  acid,  and 
the  use  by  the  patient  of  astringent  vaginal  douches,  such  as  sul- 
phate of  zinc  3ss-Oj,  alum  3j-Oj,  or  borax  3j-Oj. 


Croupous  Vaginitis. 

What  is  the  etiology  and  treatment  ? 

It  occurs  in  conjunction  with  puerperal  infection,  diphtheria,  and 
severe  forms  of  the  infectious  diseases.  The  treatment  is  the 
general  treatment  of  the  disease  and  the  local  use  of  antiseptics. 


Pelvic  Peritoneum. 

Describe. 

The  pelvic  peritoneum  is  a  continuation  of  that  lining  the  inner 
surface  of  the  walls  of  the  abdomen ;  it  covers,  more  or  less  com- 
pletely, the  pelvic  organs  (the  ovary  is  regarded  as  not  covered  by 
peritoneum),  lines  the  pelvic  walls  and  also  the  floor  of  the  pelvis. 
Traced  from  before  backward,  in  the  median  line,  it  leaves  the 
anterior  abdominal  wall  about  1J  inches  above  the  symphysis,  is 
reflected  over  the  fundus  of  the  bladder  and  down  its  posterior 
surface  to  about  the  level  of  the  internal  os ;  it  then  passes  over 
to  the  uterus,  covers  its  anterior  surface  above  that  point,  passes 
over  the  fundus  and  down  its  posterior  surface  to  the  vaginal 
junction,  thence  down  the  vaginal  wall  for  about  an  inch ;  it  then 
passes  to  the  rectum,  covers  the  anterior  surface  of  the  middle 
portion,  and  surrounds  the  upper  portion  completely.  The  pelvic 
peritoneum  is  thrown  into  several  folds  and  forms  several  pouches. 

Describe  the  folds  and  pouches  of  the  pelvic  peritoneum. 

The  principal  folds  are  the  broad,  utero-vesical  and  utero-sacral 


94  ESSENTIALS   OF   GYNAECOLOGY. 

ligaments  (so-called).  The  broad  ligaments,  extending  from  the 
sides  of  the  uterus  to  the  sides  of  the  pelvis,  in  front  of  the 
sacro-iliac  synchondrosis,  divide  it  into  two  fossae,  the  anterior  and 
posterior  ;  these  are  also  subdivided,  the  anterior  by  the  utero- 
vesical  ligaments,  the  posterior  by  the  utero-sacral.  The  pouch 
between  the  utero-vesical  ligaments  is  called  the  utero-vesical  pouch ; 
that  between  the  utero-sacral,  the  pouch  of  Douglas,  which  is  the 
deepest  part  of  the  peritoneal  cavity. 

The  pouches  between  the  utero-vesical  and  broad  ligaments  are 
called  the  para-vesical  pouches  ;  those  between  the  utero-sacral  and 
broad  ligaments  are  called  by  Polk  the  l '  retro-ovarian  shelves. ' ' 

Two  other  pouches  are  mentioned,  which  depend  on  the  condition 
of  the  bladder  :  the  vesico-abdominal,  when  the  bladder  is  distended ; 
and  the  utero-abdominal,  when  the  bladder  is  empty  and  contracted. 

What  are  the  boundaries  of  the  utero-vesical  pouch  ? 

It  is  bounded  in  front  by  the  posterior  surface  of  the  bladder, 
behind  by  the  anterior  surface  of  the  uterus,  and  laterally  by  the 
utero  vesical  ligaments. 

What  are  the  boundaries  of  the  pouch  of  Douglas  ? 

It  is  bounded  in  front  by  the  posterior  surface  of  the  uterus  and 
the  upper  portion  of  the  posterior  vaginal  wall,  behind  by  the  rec- 
tum, and  laterally  by  the  utero-sacral  ligaments. 

What  are  the  boundaries  of  the  retro-ovarian  shelves  ? 

They  are  triangular  in  shape,  bounded  in  front  by  the  base  of  the 
broad  ligament,  internally  by  the  utero-sacral  ligament,  and  exter- 
nally by  the  wall  of  the  pelvis. 


Pelvic  Peritonitis. 

What  is  the  pathology  ? 

The  peritoneum  first  becomes  hypersemic  ;  it  loses  its  lustre,  and 
exudation  materials  are  poured  out. 

1.  There  may  be  scarcely  any  serum  exuded  ;  the  inflamed  area 
is  coated  with  fibrin,  and  adhesions  form,  binding  together  the  pelvic 
organs  and  intestines, 


PELVIC   PERITONITIS.  95 

2.  The  exudation  may  consist  largely  of  serum,  either  free  in  the 
peritoneal  cavity,  or  encapsulated  by  adhesions. 

3.  The  exudation  in  severe,  especially  septic  cases  is  often  puru- 
lent. 

Hence  the  varieties  : — 

a.  Adhesive. 

b.  Serous. 
d.  Purulent. 

What  is  the  etiology  ? 

In  a  general  way,  the  etiology  of  pelvic  peritonitis  may  be  stated 
as  an  extension  to  the  peritoneum  of  inflammation  of  the  uterus, 
ovaries  or  tubes  ;  in  a  large  majority  of  the  cases,  inflammation  of 
the  tubes. 

There  may  be  first  an  endometritis,  then  a  salpingitis,  and  then  a 
peritonitis ;  or  the  infection  may  extend  by  the  way  of  veins  and 
lymphatics  from  the  uterus  into  the  broad  ligament,  and  from  there 
infect  peritoneum  without  the  intervention  of  the  tube. 

Individual  causes  are  as  follows  :  — 

a.  Introduction  of  sepsis  during  parturition,  abortion  or  operations. 

b.  Gonorrhoea. 

c.  Introduction  into  the  uterus  of  septic  instruments. 

d.  Injection  of  fluids  through  uterus  and  tubes  into  the  peritoneal 
cavity. 

e.  Catching  cold  during  menstruation. 

/.  Tubercular  or  cancerous  disease  of  the  pelvic  organs. 
g.  Tumors  causing  irritation  of  the  peritoneum. 
h.  Pelvic  cellulitis  and  peritonitis  are  often  associated  as  being 
produced  by  the  same  causes. 

What  are  the  symptoms  ? 

Pelvic  peritonitis  may  be  either  acute  or  chronic. 

Acute  pelvic  peritonitis  is  usually  ushered  in  by  a  rigor;  this, 
however,  is  not  always  present.  There  are  pain  and  tenderness  in  the 
lower  part  of  the  abdomen  ;  patient  lies  on  the  back,  with  the  knees 
elevated ;  the  pulse  is  small,  wiry  and  rapid ;  the  temperature  is 
elevated,  101°-103°,  sometimes  higher;  nausea  and  vomiting  are  com- 
mon ;  more  or  less  tympanites  is  present ;  the  bowels  are  constipated ; 
there  is  frequently  irritability  of  the  bladder ;  often  menorrhagia. 

Chronic  peritonitis  may  exist  and  present  scarcely  any  symptoms 


96  ESSENTIALS   OF  GYNECOLOGY. 

save  a  dull  pain  in  the  pelvis ;  usually,  there  is  vesical  and  rectal 
irritability,  dyspareunia,  leucorrhcea,  and  a  disturbance  of  menstrua- 
tion, especially  menorrhagia. 

Chronic  peritonitis  may  follow  the  acute,  or  may  begin  as  chronic. 

Pelvic  peritonitis  is  often  characterized  by  exacerbations. 

What  are  the  physical  signs  of  acute  pelvic  peritonitis  ? 

The  vagina  is  hot  and  dry ;  pressure  in  either  fornix,  or  on  the 
abdomen,  is  intensely  painful ;  the  bimanual  is  impracticable ;  the 
uterus,  tubes  and  ovaries  are  usually  bound  fast ;  the  slightest 
attempt  to  move  them  causes  intense  pain.  The  fornices  may  seem 
to  be  covered  by  a  hard,  flat  roof,  formed  by  a  matting  together  of 
the  pelvic  contents,  often  compared  to  plaster-of-Paris  poured  into 
the  pelvis  and  hardened  ;  you  may  feel  a  tumor  close  to  the  uterus, 
consisting  of  serum  or  pus,  roofed  in  by  adhesions  ;  the  most  com- 
mon situation  of  this  tumor  is  in  the  pouch  of  Douglas. 

What  are  the  common  results  of  pelvic  peritonitis  ? 

Displacement  of  uterus,  ovaries  and  tubes,  the  tubes  being  often 
distorted  and  stenosed  by  the  traction  of  adhesions  ;  as  a  result  of 
these  conditions  we  get  disturbances  of  menstruation,  sterility  and 
ectopic  gestation. 

What  is  the  prognosis  of  pelvic  peritonitis  ? 

Simple  adhesive  peritonitis  often  ends  in  complete  recovery  ;  dis- 
placement of  the  pelvic  organs  may  remain,  however,  and  give  rise 
to  symptoms.     The  prognosis  of  purulent  peritonitis  is  grave. 

What  is  the  treatment  of  pelvic  peritonitis  ? 

In  the  acute  form,  keep  the  patient  quiet  in  bed,  give  fluid  diet, 
apply  cold  to  the  lower  portion  of  the  abdomen,  either  in  the  form 
of  the  ice-bag  or  cold-water  coil.  In  some  cases  hot  applications 
are  more  grateful  to  the  patient ;  if  there  is  great  pain,  give  a  little 
morphine  ;  after  a  few  days,  move  the  bowels  gently,  as  by  calomel 
gr,  j  every  hour  for  3-4  doses,  assisted,  if  necessary,  by  an  enema. 
After  the  acute  stage  has  passed  use  hot  douches,  and  in  chronic 
cases,  iodine  externally  and  per  vaginam,  and  vaginal  tampons  of 
boroglyceride  or  ichthyol  and  glycerine.  A  wet  towel,  covered  by  a 
dry  one  for  a  protective,  worn  about  the  pelvis  at  night,  is  sometimes 


PELVIC  CELLULITIS.  97 

of  value  in  chronic  peritonitis.  Look  after  the  general  health  by 
attention  to  fresh  air,  administering  tonics,  and  regulating  the 
bowels. 

Pelvic  Cellulitis. 

What  are  the  principal  situations  of  the  cellular  tissue  in  the 
pelvis  ? 

1.  Between  the  abdominal  wall  and  peritoneum,  behind  the  pubes, 

2.  In  front  of  and  behind  the  cervix. 

3.  In  the  broad  ligaments. 

4.  In  the  utero-sacral  ligaments. 

What  is  the  etiology  of  pelvic  cellulitis  ? 

The  etiology  of  pelvic  cellulitis  may  almost  invariably  be  summed 
up  in  two  words — traumatism  and  sepsis  ;  the  traumatism  being, 
usually,  labor,  abortion,  or  operations  on  the  cervix. 

Pelvic  cellulitis  was  formerly  considered  very  common,  but  in  the 
light  of  recent  experience,  gained  by  laparotomies,  the  "masses," 
"thickenings,"  etc.,  are  most  often  found  to  be  salpingitis  and 
peritonitis. 

In  other  words,  pelvic  cellulitis,  although  it  does  exist,  is  com- 
paratively infrequent. 

What  is  the  pathology  ? 

There  is  an  exudation  of  serum,  fibrin  and  white  cells  ;  this  may 
resolve,  it  may  form  new  connective  tissue,  cicatricial  tissue,  or  it 
may,  and  often  does,  suppurate.  If  suppuration  occurs,  the  pus 
may  point  above  the  pubes  ;  this  is  especially  common  in  puerperal 
cases.  It  frequently  ruptures  into  the  vagina,  bladder  or  rectum, 
sometimes  into  the  uterus  ;  it  occasionally  makes  its  way  through 
the  sciatic  or  obturator  foramen  ;  rarely,  it  ruptures  into  the  peri- 
toneal cavity. 

What  are  the  symptoms  of  pelvic  cellulitis  ? 

The  disease  is  usually  ushered  in  by  a  rigor,  which  is  often  marked ; 
the  temperature  rises,  103°-105°  ;  the  pulse  is  full  and  rapid  ;  the 
pain  is  not  very  acute  ;  nausea  is  occasionally  present ;  vomiting  is 
usually  absent,  unless  peritonitis  is  a  complication.  If  pus  forms, 
septic  symptoms  become  pronounced.  There  is  often  irritability  of 
bladder  and  rectum, 
7 


98  ESSENTIALS   OE  GYNAECOLOGY. 

Chronic  cases  may  present  few  symptoms  save  a  feeling  of  weight 
in  the  pelvis,  irritability  of  bladder  and  rectum,  and  menorrhagia. 

What  are  the  physical  signs  ? 

Usually,  there  is  a  tense,  elastic  tumor  bulging  into  the  vagina, 
most  commonly  on  the  left  side,  pushing  uterus  over  to  the  right ; 
it  is  sensitive,  but  not  acutely  so.  Sometimes  the  inflammatory 
process  involves  nearly  all  the  connective  tissue  of  the  pelvis,  and  the 
exudation  can  be  felt  in  the  iliac  fossae  and  above  the  pubes.  When 
pus  forms  you  have  the  physical  signs  of  an  abscess — tenderness, 
fluctuation,  etc. 

From  what  should  you  differentiate  pelvic  cellulitis  ? 

From —  a.  Pelvic  peritonitis. 

b.  Pelvic  haeniatocele. 

c.  Fibroid  tumor  of  uterus. 

d.  Impaction  of  faeces. 

e.  Ovarian  tumor. 
/  Salpingitis. 

How  would  you  differentiate  pelvic  cellulitis  from  pelvic 
peritonitis  ? 

In  many  cases  it  is  almost  impossible  to  differentiate  the  two  ; 
they  frequently  complicate  each  other.  The  chief  points  of  difference 
are  these  :  Pelvic  cellulitis  almost  never  occurs  except  after  labor, 
abortion,  or  operation  on  the  cervix  ;  pelvic  peritonitis  may  arise 
from  any  cause  of  inflammation  of  the  uterus  or  its  adnexa,  which 
may  extend  to  the  peritoneum.  Pain  and  tenderness,  as  a  rule, 
are  less  marked  in  cellulitis  than  in  peritonitis.  Cellulitis  is  more 
apt  to  bulge  into  the  vagina  than  is  peritonitis.  Cellulitic  deposits 
are  more  apt  to  suppurate  than  are  peritonitic.  Vomiting  is  less 
frequent  in  cellulitis  than  in  peritonitis. 

How  would  you  differentiate  pelvic  cellulitis  from  pelvic 
hematocele  ? 

Chiefly  by  the  history  of  an  haematocele,  i.  e. ,  sudden  sharp  pain, 
pallor,  faintness,  and  the  physical  signs  of  a  collection  of  fluid  which 
afterward  coagulates  and  hardens.  The  above  symptoms  of  shock 
and  hemorrhage  are  wanting  in  cellulitis. 


PELVIC  CELLULITIS.  99 

How  would  you  differentiate  cellulitic  or  peritonize  deposits 
from  fibroids  of  the  uterus  ? 

Cellulitic  or  peritonitic  deposits    vs.  Fibroid  tumors. 

History  of  acute  inflammation.        Slow  growth. 

Pain  and  tenderness.  Insensitive. 

Less  plainly  outlined.  Outlines  more  distinct.  _ 

Less  intimately  connected  with      Closely     connected     with     the 

the  uterus.  uterus. 

Perhaps  menorrhagia  during  the      Usually  menorrhagia,   gradually 

acute    stage,    then    irregular         increasing  till  the  menopause. 

menstruation. 
How  would  you  differentiate  impaction  of  faeces  from  pelvic 
peritonitis  or  cellulitis  ? 

In  impaction  of  fseces,  the  mass  is  sausage-shaped,  has  a  doughy 
feel,  is  situated  in  the  position  of  the  rectum,  and  is  less  closely  con- 
nected with  the  uterus  than  an  exudation  of  peritonitis  or  cellulitis ; 
it  is  not  as  tender  on  pressure,  and  gives  no  history  of  acute  inflam- 
mation.    The  diagnosis  is  made  certain  by  clearing  out  the  rectum. 

How  would  you  differentiate  a  small  ovarian  tumor  from 
pelvic  peritonitis  or  cellulitis  ? 

There  are  no  signs  of  acute  inflammation  as  in  cellulitis  or  perito- 
nitis ;  the  ovarian  cyst  is  usually  fluctuating  ;  its  multilocular  char- 
acter can  sometimes  be  felt.  The  menstrual  disturbances  common 
in  peritonitis  and  cellulitis  are  usually  absent  in  cases  of  ovarian  cysts ; 
an  ovarian  cyst  gradually  increases  in  size. 

How  would  you  differentiate  pelvic  cellulitis  from  salpin- 
gitis ? 

By  a  careful  bimanual,  in  a  case  of  salpingitis,  you  can  generally 
map  out  an  enlarged,  tortuous  tube,  usually  distended,  extending 
from  the  side  of  the  uterus  to  the  region  of  the  ovary  ;  if  distended 
with  fluid,  you  may  detect  fluctuation.  It  does  not  bulge  into  the 
vagina  as  does  cellulitis. 

The  history  of  the  case  is  of  value  in  the  diagnosis. 

What  is  the  treatment  of  pelvic  cellulitis? 

1.  Prophylactic  :—  . 

Strict  cleanliness  and  antiseptic  precautions  during  labor,  abortion, 

operations,  etc. 


100  ESSENTIALS   OF   GYNAECOLOGY. 

2.  Abortive  : — 

Put  patient  to  bed,  apply  cold  to  the  lower  portion  of  abdomen. 

3.  When  exudation  has  occurred : — 

Apply  heat  to  the  abdomen,  administer  hot-water  vaginal  douches, 
move  bowels,  and  attend  to  the  general  health. 

4.  If  the  exudation  suppurates: — 

As  soon  as  pus  is  detected,  incise  under  antiseptic  precautions  and 
drain.  The  two  most  favorable  sites  for  incision  are  through  the 
vagina  and  through  the  abdominal  wall  just  above  Poupart's  liga- 
ment. In  doubtful  cases  it  is  sometimes  advisable  to  open  the 
abdomen  in  the  median  line,  and  then  determine  by  the  relations 
of  the  mass,  the  best  mode  of  procedure.  This,  however,  is  rarely 
necessary. 

Pelvic  Hematocele  and  Hematoma. 

Define,  and  give  the  pathology. 

Pelvic  hematocele  is  an  effusion  of  blood  into  the  cavity  of  the 
pelvic  peritoneum. 

Pelvic  hematoma  is  an  effusion  of  blood  into  the  connective  tis- 
sue of  the  pelvis  beneath  the  peritoneum,  usually  between  the  folds 
of  the  broad  ligaments. 

In  a  pelvic  hematocele,  the  effusion  is  usually  into  the  pouch  of 
Douglas ;  if  this  is  closed  by  adhesions,  or  if  the  effusion  is  very 
large,  the  blood  may  flow  over  into  the  utero-vesical  pouch.  The 
former  condition  gives  rise  to  the  name  retro -uterine,  the  latter  to 
ante-uterine  hematocele.  The  blood  is  at  first  fluid ;  it  then  slowly 
coagulates  and  is  roofed  in  by  peritonitic  exudate  binding  together 
adjacent  structures  : — coils  of  intestine,  omentum,  uterus,  etc.  This 
blood  mass,  if  small,  may  be  absorbed ;  usually,  however,  it  is  due 
to  a  ruptured  ectopic  gestation  sac  or  a  tubal  abortion  and  under 
these  circumstances  recurrent  hemorrhages  into  the  mass,  sufficient 
to  burst  its  limiting  wall  are  common.  Occasionally,  apparently 
from  proximity  to  the  intestine,  it  suppurates. 

What  is  the  etiology  of  pelvic  hematocele  ? 

Formerly  long  lists  of  causes  were  given  for  this  condition.  We 
now  know  that  in  most  cases  it  is  due  to  a  ruptured  ectopic  gesta- 
tion sac  or  a  tubal  abortion.  It  is  probable  that  exceptions  to  this 
rule  occasionally  occur,  such  as — 


PELVIC   HEMATOCELE  AND   HEMATOMA.  101 

Rupture  from  traumatism  of  vascular  peritonitic  adhesions. 
Oozing  after  removal  of  diseased  tubes  and  ovaries. 
Excessive  haemorrhage  from  the  rupture  of  a  Graafian  follicle. 
Rupture  of  an  ovarian  hsematoma. 

What  is  the  etiology  of  pelvic  haematoma  ? 

Here  again  a  rupture  of  an  ectopic  gestation  sac  is  a  very  com- 
mon cause.  Other  causes,  however,  are  probably  more  frequent 
than  in  the  case  of  pelvic  haematocele,  for  varix  of  the  broad  liga- 
ment, due  to  various  causes  of  venous  congestion  is  common,  and 
when  such  a  varix  exists,  but  a  slight  traumatism  is  needed  for  a 
blood  effusion. 
What  are  the  symptoms  of  pelvic  haematocele  ? 

A  sudden  sharp  pain,  and  symptoms  of  shock  and  hemorrhage. 
The  face  becomes  pallid,  the  expression  anxious  ;  the  pulse  is  rapid 
and  feeble ;  temperature  subnormal ;  surface  covered  with  a  cold 
perspiration :  perhaps  nausea  and  vomiting.  Later  if  the  patient 
survive,  we  have  symptoms  of  peritonitis  and  of  pressure,  either 
from  the  effusion  or  the  displaced  uterus.  The  pain  and  tenderness 
continue  for  several  days ;  there  is  usually  painful  defecation  and 
dysuria ;  usually  metrorrhagia  is  present.  In  a  few  days,  if  sup- 
puration does  not  occur,  the  effusion  diminishes  in  size  and  the 
symptoms  abate.     If  suppuration  occurs,  septic  symptoms  appear. 

The  above  are  the  symptoms  of  a  well-marked  case  ;  where  the 
effusion  is  small  the  symptoms  may  be  much  less  severe. 

How  do  the  symptoms  of  pelvic  haematoma  compare  with 
those  of  pelvic  haematocele  ? 

In  pelvic  haematoma  there  is,  as  a  rule,  less  pain  and  less  shock. 
If  the  effusion  is  large,  however,  there  may  be  the  symptoms  of 
shock  and  hemorrhage. 

What  are  the  physical  signs  of  pelvic  haematocele  ? 

At  first  no  tumor  is  felt ;  only  an  indistinct  sensation  of  fulness 
in  the  pouch  of  Douglas ;  as  the  blood  coagulates  and  is  roofed  in 
by  adhesions,  one  can  feel  a  boggy  tumor  bulging  downward  in  the 
posterior  vaginal  fornix  and  pushing  the  uterus  forward. 

What  are  the  physical  signs  of  pelvic  haematoma? 

In  this  case  there  is  felt  a  distinct  tumor  even  at  first ;  it  bulges 


102  ESSENTIALS   OF  GYNECOLOGY. 

down  on  one  side  of  and  behind  the  cervix  ;  pushes  the  uterus  for- 
ward and  to  the  opposite  side ;  seems  attached  to  the  side  of  the 
pelvis  and  can  be  felt  above  Poupart's  ligament  when  it  has  opened 
out  the  folds  of  the  broad  ligament  and  lifted  up  the  peritoneum 
from  the  pelvis.  A  finger  introduced  into  the  rectum  will  usually 
detect  a  stricture. 

What  is  the  prognosis  of  pelvic  hematocele  ? 

The  prognosis  is  usually  that  of  ruptured  ectopic  gestation  and 
will  be  discussed  under  that  condition. 

What  is  the  prognosis  of  pelvic  hematoma  ? 

Usually  good.  If  the  effusion  suppurates,  the  prognosis  is  less 
favorable.  It  may  rupture  into  rectum,  vagina,  bladder,  or  rarely 
above  the  pelvic  brim. 

How  would  you  differentiate  pelvic  haematocele  from  acute 
pelvic  peritonitis  ? 

Pelvic  hcematocele  vs.  Acute  pelvic  peritonitis. 

History  of  sudden,  sharp  pain,  Less  sudden  in  onset ;  symptoms 

with  symptoms  of  shock  and  of   shock    and    hemorrhage 

hemorrhage.  wanting. 

Absence  of  acute  inflammation  Symptoms  of  acute  inflammation 

at  first.  at  first. 

Uterus    usually    displaced    for-  Uterus  fixed,  not  markedly  dis- 

ward.  placed. 

How  would  you  differentiate  pelvic  haematocele  from  a  fibroid 
tumor  of  the  uterus  ? 

Pelvic  hcematocele  vs.  Fibroid  tumor. 

History  of  sudden,  sharp  pain  Of    slow    growth  ;     symptoms 

and  symptoms  of  shock  and  gradually  developed. 

hemorrhage. 

Soon   followed  by  signs  of  in-  Absence  of  signs  of  inflamma- 

flammation.  tion. 

Less  intimately  connected  with  More  intimately  connected  with 

the  uterus.  the  uterus  ;  moves  with  it, 

Sensitive  to  pressure.  Insensitive  to  pressure. 

Density  less.  Density  greater. 


PELVIC   HEMATOCELE  AND   HEMATOMA.  103 

How  would  you  differentiate  pelvic  hematocele  from  a  retro- 
flexed  or  retroverted  uterus  ? 

Pelvic  hematocele  vs.  Retroflexed  or  retroverted  uterus. 

Acute  history  of  pain,  shock  and      Usually  a  long  history. 

hemorrhage. 
Fundus  of  uterus   usually  lies      Fundus    backward ;     absent    in 

forward.  front. 

Sensitive  to  pressure.  Less  sensitive,  unless  surrounded 

by  peritonitis. 

How  would  you  differentiate  pelvic  hsematocele  from  an 
ovarian  cyst  ? 

Pelvic  hematocele  vs.  Ovarian  cyst. 

Acute  history  of  pain,  shock  and      History  of  slow  growth,  with  few 

hemorrhage.  general  symptoms. 

More  sensitive  to  pressure.  Less  sensitive  to  pressure. 

First  elastic  and  soft,  then  hard.       Usually  fluctuating  throughout. 

How  would  you  differentiate  pelvic  hsematocele  from  im- 
pacted faeces  ? 

By  the  history,  rectal  examination,  and  thorough  emptying  of  the 
rectum. 

How  would  you  differentiate  pelvic  hsematocele  from  retro- 
uterine carcinoma  ? 

Pelvic  hematocele  vs.       Retro-uterine  carcinoma, 

Acute  history  of  pain,  shock  and      History  of  a  chronic  disease. 

hemorrhage. 
Uterus  usually  pushed  forward.      Uterus  but  little  displaced. 

How  would  you  differentiate  pelvic  hsematoma  from  pelvic 
cellulitis  ? 

Pelvic  hcematoma  vs.  Pelvic  ceUiditis. 

History  of  sudden,  sharp  pain,  History  of   labor,    abortion,    or 

perhaps  symptoms  of  shock  operation  on  the  cervix. 

and  hemorrhage. 

Signs  of  acute  inflammation  ab-  Signs    of    acute    inflammation 

sent  at  first.  from  the  first. 

Less  sensitive.  More  sensitive. 


104  ESSENTIALS   OF  GYNAECOLOGY. 

What  is  the  treatment  of  pelvic  hsematoma  ? 

Keep  the  patient  quiet  in  bed :  at  first  apply  cold,  later  heat, 
both  externally  in  the  form  of  poultices  and  per  vaginam  by  hot 
water  douches.  If  suppuration  occurs,  open  and  drain  through 
the  vagina.  If  repeated  hemorrhages  are  added  to  this  hematoma 
two  courses  are  open  according  to  the  size  of  the  tumor.  If  the 
tumor  is  small  and  low  in  the  pelvis,  incise  through  the  vagina, 
clean  out  clots,  etc.,  and  drain.  If  the  tumor  is  large  and  extends 
high  in  the  pelvis,  it  is  probably  better  to  open  the  abdomen  and 
govern  the  treatment  by  the  condition  found. 

The  treatment  of  pelvic  hematocele  will  be  considered  under 
ectopic  gestation. 


MENSTRUATION. 

Define. 

Menstruation  is  a  periodical  series  of  phenomena,  the  most  marked 
of  which  is  a  discharge  of  blood  from  the  uterine  mucous  membrane, 
beginning,  on  an  average,  in  this  country,  at  fourteen,  and  recurring 
monthly  till  forty-five.  The  relation  of  menstruation  to  ovulation  is 
still  unsettled.  As  a  rule  they  are  simultaneously  present  or  absent, 
but  either  may  be  present  for  a  short  time  without  the  other. 

Describe  the  factors  which  influence  the  onset  of  menstrua- 
tion ;  what  is  the  average  frequency  and  duration  of 
each  period  ? 

In  temperate  climates,  menstruation  usually  appears  at  13-15 
years ;  it  is  earlier  in  warmer  climates,  later  in  cooler ;  it  appears  in 
girls  who  live  an  indoor,  city  life,  earlier  than  in  the  country.  The 
periods  normally  appear  every  28  days,  but  in  this  there  are  great 
variations ;  some  women  in  perfect  health  menstruate  every  3  weeks, 
some  only  every  5  weeks. 

The  average  duration  of  each  period  is  3-4  days,  but  this  varies 
between  2  and  8.  The  discharge  of  blood  is  usually  slight  at  first, 
reaches  maximum  on  the  second  or  third  day,  then  gradually  dimin- 
ishes. 


MENSTRUATION — AMENORRHEA.  105 

Discuss  the  normal  menopause  and  the  deviations  from  the 
normal. 

The  menopause  occurs  anywhere  from  the  fortieth  to  fiftieth 
year.  Probably  the  majority  of  women  have  it  between  the  forty- 
third  and  forty-fifth  year.  It  seldom  occurs  suddenly,  but  for  a  year 
or  two  the  intermenstrual  periods  lengthen  and  the  flow  becomes 
scant.  There  is  a  popular  belief  that  profuse  flow  or  hemorrhages 
are  to  be  expected  at  the  time  of  the  climacteric.  When  this  is  the 
case  it  is  always  an  evidence  of  disease.  This  is  the  decade  which 
brings  most  trouble  from  fibroids  and  carcinoma.  Hyperplastic 
endometritis  causes  some  of  the  hemorrhages.  Skipped  periods, 
the  result  of  pregnancy  at  this  time,  are  likely  to  be  attributed  to 
the  menopause.  Very  rarely  repeated  hemorrhages  at  this  time 
require  removal  of  a  uterus  which,  on  microscopic  examination, 
shows  only  arteriosclerosis,  atrophy  of  uterine  muscle,  or  chronic 
metritis. 


Disorders  of  Menstruation. 

Amenorrhea. 

Define. 

Amenorrhoea  is  the  absence  of  menstruation  between  puberty  and 
the  menopause.  It  is  the  normal  condition  during  pregnancy  and 
lactation.  Menstruation  may  be  present,  but  ' '  concealed, ' '  due  to 
atresia  of  the  lower  part  of  the  genital  tract.  It  may  be  divided 
into : — 

a.  Emansio  mensium — 

Where  menstruation  has  never  appeared. 

b.  Suppresio  mensium — 

Where  menstruation  has  appeared,  but  fails  to  reappear. 

What  is  the  etiology  of  amenorrhea  ? 

The  most  frequent  cause  is  anaemia,  especially  that  form  called 
chlorosis.  Other  causes  are  phthisis,  or  other  debilitating  diseases ; 
acute  diseases  at  puberty ;  non-development  of  the  generative  organs ; 
atrophy  of  the  generative  organs ;  increasing  obesity ;  removal  of 
ovaries  and  tubes  by  operation  ;  hyperinvolution  of  uterus ;  change 
of  climate,  as  the  amenorrhoea  of  immigrants ;  excessive  curettage 


106  ESSENTIALS   OF   GYNECOLOGY. 

or  cauterization  of  the  uterus.  It  has  resulted  a  number  of  times 
from  treating  the  interior  of  the  uterus  with  live  steam,  a  procedure 
known  as  atmokausis. 

What  are  the  symptoms  ? 

Amenorrhoea  is  itself  more  a  symptom  than  a  disease,  and  the 
symptoms  which  usually  accompany  amenorrhoea  are  those  of  the 
disease  which  causes  it — most  frequently  anaemia  or  phthisis.  Thus, 
from  anseniia  we  have : — 

Pallor. 

Dyspnoea  and  palpitation  of  the  heart  on  exertion. 

Depraved  appetite. 

Constipation. 

Headache. 

(Edema. 

Murmur  at  the  base  of  the  heart. 

Neuralgic  pains. 

Hysteria. 
From  phthisis  we  get  the  regular  symptoms  of  cough,  emaciation 
and  night  sweats. 

"What  is  the  prognosis  ? 

When  associated  with  simple  anaemia  the  prognosis  is  good. 
When  due  to  non-development  of  the  generative  organs  the  amen- 
orrhoea usually  continues.  When  associated  with  phthisis  or  other 
wasting  disease,  the  prognosis  is  that  of  the  disease. 

What  is  the  treatment  of  amenorrhoea  ? 

a.  When  due  to  anaemia  : — 

Some  form  of  iron,  as  Blaud's  pills;  oxygen;  nourishing  food; 
fresh  air ;  regulation  of  the  bowels,  and  attention  to  the  mode  of 
life. 

b.  When  due  to  imperfect,  or  non-development  of  the  generative 
organs : — 

Determine,  under  anaesthesia,  whether  ovaries  are  present  or  not ; 
if  absent,  do  not  attempt  to  induce  menstruation.  If  the  ovaries  are 
present,  besides  attention  to  the  general  health,  the  following  methods 
may  be  employed  : — 

Hot  water  vaginal  douches  ; 

Boro-glyceride  tampons  ; 

Electricity  to  uterus  and  over  ovaries. 


MENSTRUATION— MENORRHAGIA  AND   METRORRHAGIA.        107 

c.  When  associated  with  phthisis,  or  other  wasting  disease,  the 
treatment  is  that  of  the  associated  disease. 

In  cases  of  acute  suppressio-mensium,  due  to  exposure  to  cold, 
etc. ,  rest  in  bed,  a  saline  cathartic,  hot  mustard  foot  baths,  hot  ap- 
plications to  the  pelvic  region  and  diaphoretics  internally,  may  be 
used  with  safety  and  advantage. 


Vicarious  Menstruation. 
Describe. 

Vicarious  menstruation  is  a  periodical  discharge  of  blood  from 
some  part  of  the  body  other  than  the  interior  of  the  uterus.  It  may 
occur  with  either  amenorrhcea  or  scanty  menstruation  ;  it  usually 
appears  at  about  the  time  of  the  regular  flow.  It  may  come  from 
almost  any  mucous  membrane  :  from  the  nose,  mouth,  etc.  ;  it  may 
also  come  from  the  nipple  or  from  an  open  sore ;  it  is  usually  due  to 
a  watery  condition  of  the  blood  and  a  poor  condition  of  the  blood- 
vessels.    Direct  treatment  is  usually  not  required. 


Menorrhagia  and  Metrorrhagia. 

Define. 

Menorrhagia  is  a  prolonged  or  excessive  menstrual  flow. 
Metrorrhagia  is  ' '  uterine  hemorrhage  occurring  independently  of 
the  menses." 

What  is  the  etiology? 

Menorrhagia  and  metrorrhagia  may  be  produced  by  causes  acting 
at  a  distance,  or  local,  in  or  about  the  uterus  itself.  Acting  at  a 
distance  are  : — 

1.  Obstructed  general  circulation  from  disease  of  heart,  lungs  or 
liver. 

2.  Low  condition  of  blood  and  vessels  in  certain  wasting  diseases. 
Acting  about  the  uterus  are  : — 

1.  Tumors. 

2.  Ectopic  Gestation. 

3.  Disease  of  tubes  or  ovaries. 

The  most  common  causes  are  situated  in  the  uterus  itself,  and 
among  them  are  the  following  : — 


108  ESSENTIALS   OF  GYNECOLOGY. 

1.  Subinvolution  of  the  uterus ; 

2.  Retained  secundines ; 

3.  Submucous,  or  interstitial  fibroids  ; 

4.  Polypi ; 

5.  Carcinoma; 

6.  Tuberculosis  of  uterus ; 

7.  Retro-displacements ; 

8.  Fungous  granulations  of  the  endometrium. 
The  last  is  the  most  common  cause  of  all. 

What  is  the  treatment  of  monorrhagia  and  metrorrhagia  ? 

When  due  to  causes  acting  outside  of  the  uterus,  the  treatment  is 
that  of  these  causes ;  at  the  same  time,  there  will  often  be  found 
fungous  granulations  of  the  endometrium  which  magnify  the  influ- 
ence of  the  distant  causes ;  unless  otherwise  contraindicated,  these 
fungosities  need  to  be  removed  by  the  curette  under  antiseptic  pre- 
cautions ;  the  uterine  cavity  is  then  washed  out,  and  an  application 
of  iodine  or  carbolic  acid  or  a  mixture  of  the  two  may  then  be  made 
to  tho  endometrium.  In  mild  cases  of  menorrhagia  or  metrorrhagia 
ergot  and  hydrastis  canadensis  are  of  value  even  without  the  use  of 
the  curette,  and  in  nearly  all  except  malignant  cases  after  curetting. 
Diseases  of  the  tubes  and  ovaries  and  ectopic  gestation  require  their 
own  treatment.  Fibroids  may  demand  removal  of  the  tumor  or 
hysterectomy.  Polypi  require  removal.  Carcinoma  indicates  hys- 
terectomy.    Fungous  endometritis  demands  curetting  as  above. 


Dysmenorrhea. 
Define. 

' '  Dysmenorrhcea  may  be  defined  as  the  occurrence  of  pain  just 
before,  during  or  after  the  menstrual  period ' '  (Hart  and  Barbour). 

What  are  the  varieties  of  dysmenorrhea  ? 

The  following  varieties   are   mentioned,  but   seldom   distinctly 
differentiated : — 

1.  Obstructive ; 

2.  Congestive; 

3.  Neuralgic; 

4.  Ovarian ; 

5.  Membranous. 


MENSTRUATION — DYSMENORRHEA.  109 

The  above,  like  all  classifications  of  dysmenorrhoea,  is  not  alto- 
gether satisfactory.  Some  replace  the  word  l '  obstructive ' '  by 
"  mechanical,"  and  include  under  the  term  not  only  obstruction  to 
the  outflow  of  blood  from  the  uterus,  but  also  conditions,  as,  for 
instance,  flexions,  in  which  the  normal  menstrual  erection  of  the 
organ  is  rendered  difficult. 

Others  consider  the  pain  in  all  cases  largely  inflammatory.  The 
above  classification  will  be  found  of  value  chiefly  in  drawing  atten- 
tion to  some  of  the  causative  factors  of  menstrual  pain. 

There  are  women  whose  only  menstrual  pain  is  a  severe  headache. 
Other  women  become  melancholic  or  have  other  types  of  mental 
derangement,  such  as  suicidal  tendency,  though  showing  no  such 
tendency  in  the  intermenstrual  periods. 


Obstructive  Dysmenorrhea. 

What  is  the  etiology  ? 

Both  the  etiology  and  pathology  of  the  different  varieties  of 
dysmenorrhoea  are  still  far  from  settled,  but  the  conditions  usually 
associated  with  obstructive  dysmenorrhoea  are  : — 

a.  Flexions  of  the  uterus  ; 

b.  Stenosis  of  os  externum,  os  internum,  or  the  whole  cervical 

canal ; 

c.  Polypi; 

d.  Fibroids  distorting  uterine  canal ; 

e.  Long,  conical  cervix  ; 

f.  Spasmodic  contraction  of  os  internum. 

What  are  the  symptoms  ? 

Intermittent,  cramp-like  pains,  accompanying  the  expulsion  of 
blood  clots  which  have  formed  above  the  obstruction ;  this  expulsion 
is  followed  by  relief.  A  sound  passed  between  the  periods  usually 
shows  hypersesthesia  of  the  internal  os. 

What  is  the  treatment  ? 

During  the  intermenstrual  period  dilate  the  cervical  canal  with 
one  of  the  dilators  of  the  glove-stretcher  variety.  If  there  seems 
to  be  any  endometritis  present,  curette  the  uterus  and  wash  it  out. 
Pack  the  cavity  with  iodoform  gauze,  and  unless  the  pain  is  severe 
leave  it  for  forty-eight  hours ;  this  will  maintain  the  dilatation  for 


110  ESSENTIALS   OF  GYNECOLOGY. 

quite  a  period.  In  order  to  prevent  future  recontraction,  the  occa- 
sional introduction  of  graduated  sounds  is  of  value.  All  this  must 
be  done  under  strict  asepsis.  For  the  temporary  relief  of  the 
several  varieties  of  dysmenorrhea  the  preparations  of  viburnum 
are  of  value. 

Congestive  Dysmenorrhea. 
What  is  the  etiology  ? 

"Congestive  dysmenorrhea  depends  upon  an  advance  of  the 
menstrual  congestion  beyond  the  physiological  limits ' '  (Reeve). 

The  conditions  associated  with  congestive  dysmenorrhosa  are  the 
following : — 

a.  Exposure  to  cold  ; 

b.  Defective  general  circulation ; 

c.  Metritis ; 

d.  Endometritis ; 

e.  Displacements  of  the  uterus  ; 
/    Pelvic  tumors ; 

g.  Pelvic  peritonitis. 

What  are  the  symptoms  ? 

Between  the  periods  there  are  usually  symptoms  of  pelvic  trouble, 
or  defective  general  circulation. 

Just  before  the  flow  begins,  there  appear  feelings  of  weight  and 
heat  in  back  and  pelvis,  headache,  flushing  of  the  face,  and  some 
rise  of  temperature  ;  the  pulse  is  rapid.  The  symptoms  are  usually 
relieved  by  a  free  flow. 

What  is  the  treatment  ? 

a.  During  the  attack — 

1.  Hot  mustard  foot-baths ; 

2.  Hot  sitz -baths ; 

3.  Diaphoretics,  such  as  Dover's  powder; 

4.  Hot  pelvic  applications. 

5.  The  coal-tar  antipyretics. 

b.  During  the  intermenstrual  periods — 

1.  Seek  to  remove  the  cause  ; 

2.  Scarify  cervix  occasionally ; 

3.  Employ  glycerine  tampons  ; 

4.  Avoid  excessive  coitus  and  exertion. 
Just  before  the  flow  begins,  use  hot-water  vaginal  douches. 


menstruation — dysmenorrhea.  1 1  i 

Neuralgic  Dysmenorrhea. 

What  is  the  etiology  ? 

This  frequently  occurs  in  combination  with  some  of  the  other 
forms  of  dysmenorrhcea,  especially  the  congestive  ;  it  is  most  often 
associated  with  an  indolent,  indoor  life,  anaemia,  malnutrition, 
chronic  malarial  disease  or  hysteria.  Sometimes  no  cause  can  be 
assigned. 

What  are  the  symptoms  ? 

Pain,  sometimes  referred  to  uterus,  sometimes  to  ovaries,  some- 
times elsewhere  ;  it  changes  its  situation  ;  is  often  shooting  in  char- 
acter ;  usually  begins  a  little  before  the  flow  ;  is  sometimes  relieved 
by  a  free  flow.  Between  the  periods,  no  pathological  changes  can 
be  detected  in  the  pelvic  organs,  but  patient  suffers  from  neuralgia 
elsewhere — facial,  intercostal,  etc. 

What  is  the  treatment? 

Attention  to  the  mode  of  life ;  fresh  air  ;  exercise  ;  tonics,  espe  • 
cially  iron,  arsenic  and  quinine ;  at  the  onset  of  the  pelvic  pains 
employ  hot  sitz-baths  and  hot-water  vaginal  douches,  and  give  inter- 
nally such  anti-neuralgics  as  phenacetin. 

Ovarian  Dysmenorrhea. 

What  is  the  etiology  ? 

This  is  applied  to  a  class  of  cases  associated  with  disease  of  the 
ovaries,  but  the  etiology  is  far  from  settled,  and  the  class  not  distinct. 

What  are  the  symptoms  ? 

Between  the  periods  there  is  pain  and  tenderness  over  the  region 
of  the  ovary,  increased  by  exercise,  defecation  and  coitus ;  these 
symptoms  are  increased  at  the  menstrual  periods. 

Membranous  Dysmenorrhea. 
Describe. 

Membranous  dysmenorrhea  is  characterized  by  the  expulsion  at 
the  menstrual  periods  of  organized  membranes  either  as  a  whole  or 
in  pieces."  (Reeve.) 

What  is  the  etiology  and  pathology? 

These  are  both  matters  of  dispute,  but  we  usually  find  in  these 
cases  poor  general  health.      The  inner  surface  of  the  membrane 


112 


ESSENTIALS   OF  GYNECOLOGY. 


is  smooth  and  shows  the  openings  of  the  utricular  glands ;  its 
external  surface  is  rough  and  shaggy  (see  Fig.  13).  Microscopically 
it  resembles  the  decidual  membrane  occurring  in  pregnancy. 

According  to  Hart  and  Barbour,  "  It  is  of  the  greatest  importance 
to  remember  that  it  is  not  a  product  of  conception,  and  should  not 
be  mistaken  for  an  early  abortion. "  It  is  composed  of  the  super- 
ficial layer  of  the  endometrium,  with  increased  connective  tissue ; 
blood  accumulates  under  it  and  dissects  it  off.  Some  writers  refer  to 
this  condition  under  the  name  of  "exfoliative  endometritis,"  but  it 
is  more  than  doubful  whether  the  condition  is  an  inflammatory  one. 

Fig.  13. 


Sketch  of  a  Dysmenorrhoeal  Membrane  as  seen  under  Water  (Sir  J.  Y.  Simpson). 

What  are  the  symptoms  ? 

Severe  colicky  pain,  usually  recurring  at  each  period  ;  the  flow  is 
often  intermittent ;  thus  the  symptoms  resemble  those  of  obstructive 
dysmenorrhcea.     The  course  is  usually  protracted. 

How  would  you  differentiate  membranous  dysmenorrhea 
from  an  early  abortion  ? 
By  the  absence  of  chorionic  villi  and  by  the  repeated  occurrence 


STERILITY.  113 

What  other  condition  might  be  mistaken  for  membranous 
dysmenorrhcea  ? 
Ectopic  gestation.  A  similar  membrane  is  cast  off  in  the  two 
conditions.  In  ectopic  pregnancy  the  symptoms  of  early  pregnancy, 
the  presence  of  a  mass  to  the  side  of  the  uterus,  symptoms  of 
internal  hemorrhage,  and  the  fact  of  a  membrane  not  having  been 
cast  off  at  the  preceding  menstruation,  will  serve  to  eliminate  mem- 
branous dysmenorrhcea. 

What  is  the  treatment  ? 

a.  Between  the  periods — 

Dilate  the  cervix,  curette  the  uterine  canal,  and  apply  to  the 
endometrium  iodized  phenol,  pure  carbolic,  or  tincture  of  iodine. 

b.  During  the  menstrual  period — 

Use  hot  baths,  hot  applications  to  the  pelvis,  and  diaphoretics. 


Sterility. 

Discuss  sterility. 

Sterility  is  a  symptom  and  not  a  disease.  Various  authorities 
state  that  it  is  of  male  origin  in  from  10  to  50  per  cent,  of  cases. 
By  strictest  definition  it  means  an  inability  to  conceive  ;  but  used  in 
the  larger  sense,  in  the  case  of  the  female  of  inability  to  produce 
young,  we  may  divide  it  into  three  varieties:  — 

1.  Inability  to  conceive. 

2.  Inability  to  incubate  the  ovum. 

3.  Inability  to  bring  forth  a  live  child. 

As  a  cause  of  the  first  variety  might  be  mentioned  occlusion  of  any 
part  of  the  genital  tract ;  of  the  second  are  diseases  causing  abortion 
or  death  of  foetus  ;  of  the  third,  grave  general  diseases  or  toxaemias 
which  result  from  the  pregnancy  or  are  aggravated  by  it  and  would 
cause  the  death  of  the  patient  should  she  attempt  to  go  to  term. 

Mention  some  individual  causes  of  sterility. 

1.  Congenital  malformations.  These  are  rare,  with  the  exception 
of  an  infantile  type  of  uterus  characterized  by  long  cervix,  anteflex- 
ion, and  narrow  os.  In  these  cases  we  can  never  assume  the  uterus 
too  small  to  admit  of  pregnancy  if  menstruation  occurs  normally. 

2.  Septic  inflammations.  These  may  close  the  tubes,  bury  the 
ovaries  in  adhesions,  or  rarely  destroy  the  uterine  mucosa. 

S 


114  ESSENTIALS   OF   GYNAECOLOGY. 

3.  Gonorrhoea  is  the  most  important  single  cause  of  sterility.  It 
accounts  for  most  cases  of  male  sterility  and  much  of  it  in  the 
female.  Even  very  mild  gonorrhoeal  salpingitis  may  permanently 
occlude  both  tubes. 

4.  Endometritis  of  any  variety  predisposes  to  early  abortion. 

5.  Syphilis,  gout,  malnutrition,  and  wasting  diseases  cause  steril- 
ity by  arresting  ovulation,  as  indicated  by  suspension  of  menstrua- 
tion. Syphilis  in  the  later  part  of  its  course  does  not  inhibit  con- 
ception, but  causes  the  foetus  to  die  in  utero. 

6.  Uterine  displacements  are  frequently  the  cause  of  sterility,  or 
it  may  be  through  arresting  conception,  but  more  often  by  causing 
early  abortion. 

Among  other  causes  are  hyperinvolution  of  the  uterus,  fibroids, 
ovarian  tumors,  visceral  diseases,  and  toxsemias.  It  is  often  very 
difficult  to  assign  a  cause  in  an  individual  case. 

How  soon  after  marriage  is  pregnancy  likely  to  occur? 

Among  the  lower  animals,  including  most  of  the  domestic  ones,  a 
single  intercourse  usually  results  in  pregnancy.  In  the  human  spe- 
cies this  is  by  no  means  so  invariable,  chiefly  because  intercourse  is 
not  restricted  to  the  times  when  ovulation  is  occurring.  With  the 
marriage  of  normal  individuals,  unless  preventive  methods  are  em- 
ployed, pregnancy  will  occur  within  the  first  year  in  the  vast  major- 
ity of  cases,  and  in  the  larger  part  of  these  within  the  first  few 
months.  On  the  other  hand,  without  artificial  prevention  the  first 
pregnancy  may  not  occur  for  years  and  no  cause  be  assignable.  If 
two  years  have  passed  after  marriage  without  pregnancy  resulting, 
we  are  safe  in  assuming  that  some  definite  barrier  to  pregnancy 
probably  exists,  and  that  the  case  is  liable  to  be  one  of  permanent 
sterility  unless  there  is  a  removable  cause,  such  as  retroversion,  too 
narrow  os,  or  hyperplastic  endometrium. 

What  is  "  one-child  sterility  "  ? 

The  term  is  applied  to  cases  where  a  pregnancy  occurs  shortly 
after  marriage,  but  is  never  repeated.  It  is  about  as  common  as 
absolute  sterility.  In  such  cases  we  are  to  look  for  the  cause  in 
something  that  occurred  during  the  pregnancy  or  puerperium. 
Gonorrhoea  is  a  common  cause  of  the  condition,  as  is  sepsis  occur- 
ring after  labor  or  abortion.  Some  cases  result  from  subinvolution, 
displacements,  or  hyperplastic  endometrium. 


MALFORMATIONS   OF  THE  VAGINA.  115 

Malformations  of  the  Vagina. 

What  are  the  important  varieties  ? 

a.  Atresia  vaginae ; 

b.  Double  vagina; 

c.  Absence  of  vagina ; 

d.  Stenosis  of  vagina. 

Atresia  Vagina. 

Give  the  varieties  and  etiology. 

Atresia  of  the  vagina  may  be  either  at  the  hymen,  forming  atresia 
hymenalis,  or  higher  up  in  the  vagina,  forming  atresia  vaginalis. 

Etiology. — Atresia  hymenalis  is  usually  congenital,  from  mal- 
development.  Atresia  vaginalis  is  either  congenital,  or  may  be 
acquired  from  cicatrization  following — 

a.  Sloughing  incident  to  parturition  ; 

b.  Adhesive  vaginitis ; 

c.  Traumatism ; 

d.  Caustics. 

What  are  the  symptoms  of  atresia  vaginae  ? 

They  are  dependent  on  the  accumulation  of  the  menstrual  blood, 
hence  in  congenital  cases  they  are  absent  till  puberty.  The  subjective 
symptoms  of  menstruation  come  on,  but  there  is  no  appearance  of 
blood ;  at  the  next  period  the  subjective  symptoms  are  repeated. 
The  periods  then  usually  come  more  frequently,  and  soon  a  tumor 
forms.  If  the  atresia  is  at  the  hymen,  the  latter  bulges,  and  the 
vagina  is  distended  with  blood,  forming  a  hsemato-colpos. 

In  atresia  hymenalis  the  cervix  is  usually  not  dilated ;  in  atresia 
vaginalis  the  dilatation  may  extend  to  the  uterus  and  tubes. 

If  the  atresia  is  acquired,  of  course  there  will  be  no  symptoms  till 
the  menstrual  blood  is  retained. 

What  are  the  results  of  atresia  hymenalis  if  unrelieved  by 
operation  ? 

If  the  hymen  is  thin,  it  may  rupture  ;  if  thick,  the  vagina  may 
rupture  ;  after  rupture,  septicaemia  may  occur. 

What  are  the  results  of  atresia  vaginalis  ? 
The  vagina  may  rupture. 


116  ESSENTIALS   OF   GYNECOLOGY. 

The  uterus  and  tubes  may  become  distended,  forming  hsemato- 
metra  or  hseinato-salpinx,  and  may  rupture. 
The  atresia  may  rupture. 
After  rupture  septicaemia  may  occur. 

Where  else  in  the  genital  tract  than  in  the  vagina  may 
atresia  occur  ?    Give  the  etiology  and  symptoms. 

Atresia  may  occur  at  the  cervix. 

Atresia  of  the  cervix  may  be  congenital,  or  acquired  from  cicatri- 
zation following  parturition,  the  use  of  caustics,  or  from  a  too  close 
trachelorrhaphy.  Symptoms  appear  when  the  menstrual  blood  ac- 
cumulates behind  the  atresia,  and  resemble  those  of  atresia  vaginae. 
The  amenorrhoea  and  enlargement  of  the  uterus  may  make  one 
suspect  pregnancy. 

What  are  the  results  of  atresia  of  the  cervix  if  unrelieved  by 
operation  ? 

If  it  is  present  during  menstrual  life,  the  uterus  and  tubes  become 
distended,  and  are  liable  to  rupture,  with  the  danger  of  peritonitis 
and  death.  If  it  occurs  for  the  first  time  after  the  menopause,  it 
usually  causes  no  trouble. 

What  is  the  character  of  the  retained  fluid  ? 

During  menstrual  life  the  blood  is  of  a  brownish,  chocolate  color ; 
it  is  grumous  and  treacle-like  in  consistency,  kept  from  clotting  by 
the  mucus. 

After  the  menopause,  the  retained  fluid  is  honey-like,  and  the 
condition  is  spoken  of  as  hydrometra.  If  the  fluid  becomes  infected 
it  becomes  pyometra. 

What  is  the  treatment  of  atresia  of  the  genital  tract  with 
retention  of  the  menstrual  blood  ? 

Aspirate  slowly ;  under  strict  antisepsis  incise  the  obstruction,  and 
maintain  the  opening  by  iodoform  gauze  or  a  rigid  drainage-tube. 

What  are  the  dangers  of  rapid  evacuation  of  a  hsemato- 
metra  ? 

The  tubes  are  probably  distended,  and  have  formed  adhesions ; 
the  rapid  collapse  of  the  uterus  would  tend  to  tear  the  tubes  from 
their  adhesions,  with  the  danger  of  rupture  of  the  tubes,  and  perito- 
nitis. 


malformations  of  the  uterus.  117 

Stenosis  of  Vagina. 

Give  its  cause  and  describe. 

It  may  be  acquired  from  cicatrization  of  the  vagina  or  be  congeni- 
tal. The  congenital  stenosis  is  not  infrequent  just  in  front  of  the 
cervix.  It  interferes  with  coitus  and  labor  and  gives  rise  to  vaginitis 
by  interfering  with  the  drainage  of  the  upper  part  of  the  vagina. 

Malformations  of  the  Uterus. 

How  are  the  congenital  anomalies  to  be  explained  ? 
Chiefly  as  arrests  of  development : 

1.  The  Miillerian  ducts  when  first  formed  are  solid  cords,  and 
from  failure  to  become  hollowed  out,  atresia  may  result. 

2.  There  may  be  failure  of  development  of  one  or  both  ducts  or 
unequal  development  of  them,  resulting  in  uterine  asymmetry. 

3.  The  ducts  fail  to  fuse  properly,  resulting  in  a  bifid  or  septate 
organ. 

What  are  the  principal  varieties  ? 

1.  Rudimentary  uterus ; 

2.  Uterus  bipartitus ; 

3.  Uterus  unicornis  p» 

4.  Uterus  bicornis  ;  _ 

5.  Uterus  clidelphys ;  -^ 

6.  Uterus  septus ;    -, 

7.  Infantile  uterus  ;    -- 

8.  Congenital  atrophy  of  the  uterus ; 

9.  Complete  absence  of  the  uterus,  very  rare. 

Describe  the  rudimentary  uterus. 

In  this  case  (see  Fig.  14)  "the  uterus  is  represented  by  a  band  of 
muscular  fibre  and  connective  tissue  on  the  posterior  wall  of  the 
bladder."  (Hart  and  Barbour.) 

Describe  the  uterus  bipartitus. 

In  the  uterus  bipartitus  (see  Fig.  15)  the  rudimentary  horns  are 
present,  and  are  either  hollow  or  solid  and  cord-like  ;  they  are  con- 
nected to  each  other  and  to  the  vagina  by  the  cervix,  which  is  repre- 
sented by  a  fibrous  band.  The  ovaries,  breasts  and  external  genitals 
may  be  well  developed. 

Describe  the  uterus  unicornis. 
The  body  of  the  uterus  in  this  variety  (see  Fig.  16)  is  long  and 


US  ESSENTIALS   OF   GYNAECOLOGY. 

narrow,  and  is  directed  to  one  side ;  its  fundus  lias  attached  to  it  one 
Fallopian  tube  and  ovary ;  on  the  opposite  side  of  the  body  is  seen 
the  representative  of  the  other  horn,  which  is  either  solid  or  hollow ; 
connected  with  this,  and  separated  from  it  by  the  attachment  of  the 
round  ligament,  are  the  tube  and  ovary  of  that  side. 

Describe  the  uterus  bicornis. 

In  this  form  (see  Fig.  17)  the  division  into  two  horns  is  distinctly 
visible  externally  ;  the  division  is  usually  seen  also  in  the  interior  of 
the  uterus  on  section. 

What  is  the  uterus  didelphys? 

Here  the  two  halves  of  the  uterus  are  separated  throughout  (see 
Fig.  18).     This  condition  is  very  rare. 

Describe  the  uterus  septus. 

Here  the  division  is  entirely  internal  (see  Fig.  19);  beginning  at 
the  fundus,  it  extends  a  variable  distance  toward  the  os  externum, 
sometimes  reaching  it.  There  is  no  indication  of  the  division  from 
the  outside. 

What  is  an  infantile  uterus  ? 

In  this  condition  (see  Fig.  20)  the  cervix  is  2-3  times  longer  than 
the  body,  the  relation  of  cervix  to  body  remaining  as  at  birth.  The 
uterus  as  a  whole  is  smaller  than  normal. 

What  is  meant  by  congenital  atrophy  of  the  uterus  ? 

The  relative  lengths  of  cervix  and  body  (see  Fig.  21)  conform  to 
those  of  a  virgin  uterus,  but  the  whole  uterus  is  atrophied. 

What  is  the  occurrence  of  complete  absence  of  the  uterus? 

It  is  very  rare  indeed,  and  can  only  be  ascertained  by  a  post- 
mortem examination.  Many  cases  of  supposed  absence  of  the  uterus 
are  proved,  on  autopsy,  to  be  cases  of  rudimentary  uterus. 

What  are  the  importance  and  danger  of  uterine  malforma- 
tions ? 
Pregnancy  in  such  cases  may  endanger  the  patient's  life.  The 
diagnosis  is  difficult.  Menstruation  may  occur  from  one  half  and 
pregnancy  be  present  in  the  other.  The  pregnant  cornu  may  be 
mistaken  for  a  tumor  or  it  may  rupture  with  symptoms  like  those 
of  ectopic  gestation. 


MALFORMATIONS  OF  THE  UTERUS. 
Fig.  14. 


119 


Rudimentary  Uterus  (Veit).     Sa,  sacrum;    U,  solid  rudiment  of  uterus;  h .  rudl- 
Sar^hornr^/bladder;  6,  ovary;  T,  Fallopian  tube ;  r  round  ligament. 


Fig.  15. 


Uterus  Bipartitus  (Rokitansky).     V,  vagina;  U,  uterus ;  ft,  rudimentary  horn ;  0, 
ovary;  T,  tube;  r,  round  ligament ;  b,  broad  ligament. 


Fig.  16. 


Uterus  Unicornis  (Schroeder).  E,  right  side;  L,  left  side.  The  left  horn  (h)  is  well 
developed  and  communicates  with  the  uterine  cavity.  The  right  horn  is  in  the 
form  of  an  elongated  band;  its  point  of  connection  with  the  Fallopian  tube  is 
indicated  by  the  insertion  of  the  round  ligament,  which  is  hypertrophied.  Other 
letters  as  in  preceding  diagrams. 


120 


ESSENTIALS   OF  GYNECOLOGY. 


Fig.  17. 


Uterus  Bicornis  Unicollis  (Schroeder).    r,  round  ligament. 


Fig.  18. 


Uterus  Didelphys.  a,  right  cavity ;  b,  left  cavity;  c,  right  ovary ;  d,  right  round 
ligament;  e,  left  round  ligament;  /,  left  tube;  g,  left  vaginal  portion;  h,  right 
vaginal  portion;  i,  right  vagina;  j,  left  vagina;  k,  partition  between  the  two 
vaginas.    (From  De  Sinety,  after  Ollivier.) 


MALFORMATIONS   OF  THE  UTERUS. 


121 


Fig.  19. 


Fig.  20. 


Uterus  Septus  in  Vertical  Transverse  Section  (Kuss- 
maul).  [/"(uterus),  placed  on  septum  which  divides 
cavity  into  two  lateral  portions ;  T,  Fallopian  tubes ; 
V,  vagina  divided  into  lateral  cavities  by  prolonga- 
tion of  septum  downward. 


Infantile  Uterus 
(Schroeder). 


Fig.  21. 


Primary  Atrophy  of  the  Uterus  (Virchow). 


122  ESSENTIALS   OE   GYNECOLOGY. 

Displacements  of  the  Uterus. 

"What  do  we  mean  by  a  displacement  of  the  uterus  in  a 
clinical  sense  ? 

' '  Changes  in  the  position  of  the  uterus  only  become  displacements, 
in  the  clinical  sense,  when  they  are  more  or  less  stable.  Limitation 
or  hindrance  of  the  normal  movements  of  the  uterus  is  a  main 
characteristic  of  its  displacements."  (Schultze.) 

What  are  the  principal  displacements  of  the  uterus  * 

a.  Anteversion ; 

b.  Anteflexion ; 

c.  Retroversion ; 

d.  Retroflexion ; 

e.  Prolapse. 

What  is  the  difference  between  a  "version"  and  a  "flexion?" 

In  a  "version  "  the  canals  of  the  cervix  and  body  are  in  the  same 
straight  line  ;  in  a  ' l  flexion ' '  they  make  an  angle  with  each  other. 

Anteversion. 

Discuss  briefly. 

The  uterus  is  sometimes  fixed  in  a  position  of  anteversion  owing 
to  the  pressure  of  encysted  fluids,  tumors,  inflammatory  masses, 
peritoneal  adhesions,  or  increased  weight  of  the  organ.  The  symp- 
toms are  those  of  the  causal  condition.  The  anteversion,  per  se, 
gives  rise  to  no  symptoms,  hence  it  is  not  usually  considered  among 
Uterine  displacements. 

Anteflexion. 
What  is  the  pathology  ? 

In  anteflexion  the  body  of  the  uterus  is  bent  forward  on  the 
cervix  (see  Fig.  22) ;  in  order  for  this  to  be  pathological,  there  must 
be  rigidity  at  the  point  of  flexion.  The  posterior  wall  of  the  cervix 
is  elongated  by  stretching,  the  anterior  is  shortened,  and  there  is 
atrophy  at  the  angle. 

What  is  the  etiology  ? 

It  may  be  congenital  (puerile,  Schultze)  or  acquired. 


DISPLACEMENTS   OF  THE  UTERUS. 


123 


The  former  is  much  the  more  common  and  is  due  to  a  lack  of 
development  in  a  woman  whose  general  development  is  apt  to  be 
below  normal. 

The  most  common  causes  of  the  acquired  ,anteflex  ion  are  a  me- 
tritis occurring  in  a  flexible  uterus,  or  an  inflammatory  process 
occurring  in  the  utero-sacral  ligaments,  drawing  the  upper  portion 
of  the  cervix  upward  and  backward. 

Fig.  22. 


Anteflexion  of  the  Uterus  (Schroeder). 

It  is  sometimes  caused  by  the  adhesions  of  peritonitis  drawing  the 
upper  portion  of  the  cervix  backward. 

What  are  the  symptoms  ? 

a.  Dysmenorrhoea ; 

b.  Sterility ; 

c.  Disturbance  of  bladderjunctipns — frequent  micturition  ; 

d.  Leucorrhcea ; 

e.  Othersymptoms  are  those  of  the  accompanying  inflammation. 

What  are  the  physical  signs  ? 

The  cervix  lies  rather  high ;   the  os  is  directed  downward  and 
forward ;  as  you  pass  the  finger  up  along  the  anterior  wall  of  the 


124 


ESSENTIALS   OF  GYNECOLOGY. 


cervix,  it  runs  into  a  marked  angle  between  cervix  and  body.  The 
body  can  be  felt  lying  in  front  of  the  cervix,  just  above  the  anterior 
vaginal  wall.  The  cervix  is  often  long  and  the  os  small.  The 
sterility  is  more  dependent  upon  the  long  cervix  plugged  with 
mucus  than  any  actual  stenosis  of  the  internal  os.  The  uterus  is 
sometimes  both  anteflexed  and  retroverted. 

From  what  must  you  differentiate  an  anteflexion  ? 

From — 1 .  A  fibroid  tumor  in  the  anterior  wall  of  the  uterus ; 
2.  An  inflammatory  deposit  in  front  of  the  cervix. 

How  would  you  differentiate  an  anteflexed  uterus  from  a 
fibroid  tumor  in  the  anterior  wall? 

In  an  anteflexion  you  cannot  feel  the  fundus  elsewhere,  and  a 

sound  passes  when  sharply  curved 
into  the  body  felt  in  front  of  the 
cervix. 

In  a  fibroid  in  the  anterior  wall 

I  S^^A\  *\ U1Y '  W      (see  -^ig-  23)  the  sound  does  not 

pass  into  the  body  felt  in  front  of 
the  cervix,  but  behind  it,  and  the 
fundus  can  be  felt  above  and  behind 
the  fibroid. 


How  would  you  differentiate 
an  inflammatory  deposit 
from  an  anteflexion  ? 

The  former  is  comparatively  rare, 
but  when  present  is  usually  more 
sensitive  than  an  anteflexion ;  in 
the  case  of  an  inflammatory  deposit 
in  front  of  the  cervix,  a  careful 
bimanual  examination  will  usually 
show  the  fundus  elsewhere. 
During  the  acute,  inflammatory  period  the  sound  is  contraindicated. 

What  is  the  treatment  of  anteflexion  ? 

First  treat  all  existing  pelvic  inflammation,  by  means  of  hot-water 
douchesi  counter-irritation  and  glycerine  tampons.  When  all  inflam- 
matory symptoms  have  subsided,  dilate  the  cervix,  under  antiseptic 


Sound  passed  to  show  that  a  Fibroid 
of  the  Anterior  "Wall  is  not  an 
Anteflexion  (Leblond). 


DISPLACEMENTS   OF  THE  UTERUS.  125 

precautions,  with  one  of  the  glove-stretcher  dilators,  and  pack 
the  cavity  with  iodoform  gauze,  leaving  it  for  forty-eight  hours ;  or 
a  stem  pessary  long  enough  to  pass  through  the  internal  os  may  be 
inserted  and  left  in  place  while  the  patient  remains  in  bed,  say  from 
one  to  two  weeks.  Maintain  the  dilatation  by  the  introduction  of 
the  graduated  hard  dilators,  or  sounds,  once  or  twice  a  month  for 
two  or  three  months. 


Retroversion  and  Retroflexion. 
Define. 

.' 1  Retroversion  may  be  defined  as  the  permanent  dislocation  back- 
ward of  the  fundus  uteri,  when  the  form  of  the  uterus  is  such  that 
axis  of  body  and  axis  of  cervix  are  identical.  Retroflexion  denotes 
the  permanent  backward  dislocation  of  the  fundus  uteri,  with  simul- 
taneous flexion  of  the  uterus  over  the  posterior  surface. ' '  (Harrison. ) 

What  is  the  etiology  and  pathology  ? 

Retroversion  (see  Fig.  24)  may  exist  by  itself,  but  with  retroflexion 
there  is  always  more  or  less  retroversion.  Usually  the  uterus  is  first 
retroverted,  and  then  intra-abdominal  pressure  continuing,  if  the 
uterus  is  flexible,  the  fundus  is  pushed  backward  and  downward. 
The  combination  of  the  two  is  thus  most  common,  and  is  described 
as  retroversio-flexio  (see  Fig.  25).  Retro versio-flexio  is  most  fre- 
quent in  multiparse  following  parturition,  where  the  ligaments  are 
lax  and  patient  lies  on  the  back,  and  especially  if  the  patient  rises 
before- involution  has  occurred.  It  may  occur,  however,  in  nulliparae 
or  virgins,  from  severe  blows,  falls,  lifting,  straining,  etc. ;  also  from 
inflammatory  adhesions,  drawing  the  uterus  backward. 

The  most  common  agent  in  pushing  a  movable  uterus  behind  the 
perpendicular  is  distention  of  the  bladder ;  intra-abdominal  pressure 
may  then  act  on  the  anterior  surface  of  the  uterus.  Relaxation  of 
the  utero-sacral  ligaments,  and  thickening  and  shortening  of  the 
utero-vesical,  favor  retroversio-flexio. 

Pathologically,  we  usually  find  the  body  of  the  uterus  congested 
and  enlarged,  its  mucosa  hyperplastic,  and  more  or  less  rigidity  at 
the  junction  of  cervix  and  body,  from  development  of  fibrous  tissue. 


126 


ESSENTIALS   OF  GYNAECOLOGY. 


What  are  the  symptoms  ? 

1 .  More  or  less  constant  pain,  in  the  back ; 

2.  Symptoms  of  pelvic  inflammation ; 

3.  Constipation  ; 

4.  Irritability  of  the  bladder  ; 

5.  Leucorrhoea ; 

6.  Menorrhagia ; 

7.  Dysmenorrhea,  especially  when  flexion  is  marked ; 

8.  Abortion ; 

9.  Sterility^ 

10.  Keflex  neuroses. 

Fig.  24. 


Retroversion  of  the  Uterus  (Schroeder.) 


What  are  the  physical  signs  ? 

On  making  the  bimanual  examination,  you  find  the  cervix  nearer 
the  vulva  than  normal,  the  fundus  absent  in  front,  and  the  os  pointing 
more  or  less  forward  ;  on  running  the  vaginal  fingers  along  the  pos- 
terior wall  of  the  cervix,  you  find  a  body  which,  in  a  retroversion, 
continues  the  line  of  this  wall,  in  a  retroflexion  makes  an  angle  with 
it.  This  body  moves  as  a  part  of  the  uterus ;  the  sound  passes 
into  it 


DISPLACEMENTS   OF  THE  UTERUS.  127 

From  what  must  you  differentiate  retroversio-flexio  ? 

1.  Fibroid  tumor  on  posterior  wall  of  the  uterus  ; 

2.  Faeces  in  the  rectum  ; 

3.  Inflammatory  deposits ; 

4.  Prolapsed  ovaiy  or  small  ovarian  tumor. 

How  would  you  differentiate  retroversio-flexio  from  a  fibroid 
on  the  posterior  wall  ? 
Make  a  careful  bimanual  examination.  In  case  of  a  backward 
displacement  of  the  uterus,  we  find  an  absence  of  the  fundus  in  front, 
the  cervix  points  more  or  less  forward,  and  the  sound,  when  intro- 
duced, goes  backward. 

Fig.  25. 


Retroversio-flexio. 

In  case  of  a  fibroid  on  the  posterior  wall,  the  fundus  may  be  felt 
in  front  of  it,  and  the  sound  passes  forward.  The  tumor  may  feel 
more  irregular  and  harder  than  the  uterus. 

How  would  you  differentiate  the  fundus  uteri  from  faeces  in 
the  rectum  ? 

On  bimanual  examination,  the  fundus  can  often  be  felt  forward, 
and  the  sound  passes  forward  ;  the  faeces  have  a  more  doughy  feel 


128  ESSENTIALS   OF  GYNECOLOGY. 

than  the  uterus ;  if  doubt  exists,  always  empty  the  rectum  before 
making  a  diagnosis. 

How  would  you  differentiate  the  fundus  uteri  from  inflam- 
matory deposits  in  the  pouch  of  Douglas  ? 

During  the  stage  of  acute  inflammation  this  may  be  very  difficult, 
as  the  sound  is  then  contraindicated.  Finding  the  fundus  in  front 
is  the  chief  element  in  the  diagnosis. 

When  acute  inflammation  has  subsided,  introduction  of  the  sound 
will  give  great  assistance. 

How  would  you  differentiate  the  fundus  uteri  from  a  pro 
lapsed  ovary  or  small  ovarian  tumor  ? 

By  making  a  careful  bimanual  examination,  the  uterus  is  found 
lying  in  front  of  the  prolapsed  ovary  or  tumor.  Assistance  may  be 
given  by  the  use  of  the  sound,  or  drawing  down  the  cervix  with  a 
volsella. 

What  are  the  indications  in  the  treatment  of  retroversio- 
flexio  ? 

1.  To  treat  the  pelvic  peritonitis  or  cellulitis,  if  present,  according 

to  the  regular  methods ; 

2.  To  replace  the  uterus  ; 

3.  To  retain  it  in  place. 

What  are  the  methods  of  replacing  a  retroverted  or  retro- 
flexed  uterus  when  movable  ? 

1.  Place  the  patient  in  Sims'  position ;  introduce  index  and  middle 
fingers  of  the  right  hand  into  the  posterior  fornix  vaginae ;  have 
patient  breathe  deeply  and  slowly ;  during  an  expiration,  raise  the 
body  of  the  uterus  with  the  backs  of  the  vaginal  fingers  till  it  passes 
the  promontory  of  the  sacrum,  then  transfer  one  or  both  fingers  to 
the  front  of  the  cervix,  and  push  that  backward ;  this  throws  the 
fundus  forward. 

2.  Another  method  is  to  replace  the  uterus  while  patient  is  in  the 
dorsal  position,  by  means  of  the  bimanual,  either  vagino-abdominal 
or  recto-abdominal.  In  this  method  the  body  of  the  uterus  is  raised 
by  the  fingers  in  the  vagina  or  rectum  until  it  can  be  grasped  by  the 
external  hand,  when  it  is  then  brought  forward.     In  some  cases  this 


DISPLACEMENTS   OF  THE  UTERUS.  129 

operation  is  facilitated  by  first  grasping  the  cervix  with  a  vulsella 
and  pulling  it  downward  in  the  axis  of  the  vagina,  thus  straightening 
the  uterine  canal,  making  the  fundus  easier  to  reach  by  the  examin- 
ing finger  and  easier  to  lift  above  the  sacral  promontory. 

3.  When  the  body  of  the  uterus  is  very  sensitive,  so  that  pressure 
by  the  fingers  is  very  painful,  the  uterus  may  be  replaced  by  means 
of  the  sound,  as  follows :  Introduce  the  sound  with  the  concavity 
backward ;  then  make  the  handle  describe  an  arc  of  a  circle  from 
behind  forward ;  then  slowly  depress  the  handle  toward  the  perineum ; 
this  throws  the  uterus  forward. 

4.  To  replace  the  gravid  uterus,  the  following  method  is  sometimes 
employed  :  Place  patient  in  the  genu-pectoral  position  ;  draw  down 
cervix  with  the  volsella,  and  press  fundus  uteri  toward  the  bladder, 
with  the  finger  in  the  rectum. 

When  the  uterus  in  a  retroversio-flexio  is  rigid  at  the  angle  of 
flexion,  we  do  not  expect  to  remove  the  flexion,  but  only  to  correct 
the  version. 

What  are  the  methods  of  replacing  a  retroverted  or  retro- 
flexed  uterus  when  fixed  by  adhesions  ? 

If  signs  of  pelvic  inflammation  are  present,  treat  the  inflammation 
by  hot  douches,  sitz-baths,  wet  pelvic  packs,  attention  to  the  bowels, 
etc.  When  the  inflammation  has  subsided,  the  uterus  may  gradu- 
ally be  replaced  by  cautious  manipulation  and  stretching  of  the 
adhesions,  and  gentle  attempts  at  raising  the  uterus,  a  few  moments 
at  a  sitting,  with  the  fingers  in  the  posterior  fornix  vaginae ;  after  the 
manipulation  insert  a  wool  tampon,  to  be  worn  for  twenty-four  hours. 
At  first  the  tampons  are  to  be  pressed  firmly  into  the  posterior  for- 
nix to  exert  an  upward  pressure  on  the  fundus.  Later,  when  the 
fundus  can  be  nearly  replaced,  put  the  tampon  in  the  anterior  fornix 
to  press  the  cervix  backward  and  thus  maintain  the  reposition 
already  accomplished.  The  manipulations  may  be  assisted  by  hot- 
water  vaginal  douches  between  the  sittings.  It  is  well  to  have  the 
patient  assume  the  knee-chest  position  once  or  twice  daily. 

Schultze's  method  of  forcible  reposition  consists  in  placing  the 
patient  under  anaesthesia,  in  the  lithotomy  position,  inserting  index 
and  middle  fingers  of  left  hand  high  up  into  the  rectum,  and  with 
these  fingers  forcibly,  but  gradually,  elevating  the  fundus  uteri  and 
breaking  up  the  adhesions ;  the  right  hand  is  placed  on  the  abdo- 
9 


130  ESSENTIALS   OF  GYNAECOLOGY. 

men,  and  as  the  uterus  is  elevated,  it  is  grasped  by  this  external 
hand  and  brought  forward. 
This  method  is  rarely  advisable. 

What  are  the  means  for  retaining1  the  uterus  in  place  after 
reposition  ? 

1.  Pessaries ; 

2.  Operative  procedures. 

Pessaries. 

What  are  the  varieties  in  most  common  use  ? 

1.  The  Albert  Smith  ; 

2.  The  Emmet; 

3.  The  Thomas. 
Describe  them. 

They  are  usually  made  of  hard  rubber;  the  Thomas  pessary,  how- 
ever, is  often  made  of  soft  rubber. 

The  Albert  Smith  (see  Fig.  26)  is  a  modification  of  the  Hodge 
pessary ;  its  anterior  extremity  is  narrow,  the  posterior  broad ;  the 
posterior  extremity  curves  upward  behind  the  cervix,  the  anterior 
downward  away  from  the  urethra. 

The  Emmet  pessary  is  usually  made  of  a  larger  bar  than  the  Albert 
Smith,  and  the  curve  is  much  flattened. 

The  Thomas  (see  Fig.  27)  is  long,  narrow,  and  has  its  posterior 
bar  much  enlarged. 

How  does  a  retroversion  pessary  act  ? 

Not  by  pushing  up  the  body  or  fundus,  but  by  making  the  poste 
rior  vaginal  wall  tense,  thus  drawing  the  cervix  backward,  and  in 
this  way  throwing  the  fundus  forward. 

What  are  the  contraindications  to  the  use  of  a  pessary  ? 

A  pessary  should  not  be  introduced  till  all  pelvic  inflammation  has 
subsided,  and,  as  a  rule,  not  until  the  uterus  can  be  well  brought 
forward;  "but  occasionally,  when  the  uterus  is  elevated  to  about 
the  promontory,  the  pessary  may  be  applied. ' ' 

What  is  the  proper  position  of  a  retroversion  pessary  after 
introduction  ? 

The  broader  extremity  should  lie  behind  the  cervix  and  curve 
upward  ;  the  narrow  in  front  and  curve  downward. 


PESSARIES. 


131 


How  would  you  introduce  one  of  these  retroversion  pessaries  ? 

They  may  be  introduced  with  patient  either  in  the  dorsal  or  in 
Sims'  position,  preferably  in  the  latter,  and  in  the  following  manner : 
Standing  at  the  side  of  the  table,  near  the  buttocks  of  the  patient, 
separate  the  labia  a  little  with  the  fingers  of  the  left  hand  ;  taking 
the  pessary  by  the  smaller  end  with  the  thumb  and  index  and  middle 
fingers  of  the  right  hand,  introduce  it  between  the  labia,  with  the 
breadth  of  the  pessary  in  the  line  of  the  labia  (see  Fig.  28) ;  depress 
the  perineum  with  the  pessaiy  as  you  introduce  it  about  half  way, 


Fig.  26. 


Fig.  27. 


Albert  Smith  Pessary. 


Thomas  Pessary, 


then  rotate,  so  that  the  breadth  of  the  pessary  lies  at  right  angles  to 
the  labia ;  now  grasp  the  external  portion  of  the  pessary  with  the 
left  hand  ;  pass  the  index  finger  or  index  and  middle  fingers  of  the 
right  hand  in  front  of  the  posterior  bar  (see  Fig.  29)  and  carry  the 
pessary  along  the  posterior  vaginal  wall,  being  careful  that  it  does 
not  slip  up  in  front  of  the  cervix. 

What  are  the  precautions  to  be  observed  in  the  employment 
of  a  pessary  ? 

A  patient  after  the  introduction  of  a  pessary  should  be  made  to 
walk  a  little  about  the  room,  then  to  sit  on  a  chair  and  cross  one 
knee  over  the  other,  to  ascertain  if  the  pessary  causes  pain ;  if  it 
does,  it  should  not  be  kept  in.     A  patient  should  always  be  told,  on 


132 


ESSENTIALS   OF   GYNAECOLOGY. 


leaving,  that  if  the  pessary  causes  her  pain,  she  must  introduce  her 
finger  and  remove  it.  She  should  be  seen  in  a  few  days  after  its 
introduction,  to  ascertain  if  the  pessary  is  in  position  and  is  holding 
the  uterus  in  place.  If  one  is  not  able  to  insert  the  finger  between 
the  pessary  and  vaginal  wall  the  pessary  is  too  large  and  may  cause 

Fig.  28. 


Introduction  of  Pessary,  First  Stage  (Hart  and  Barbour). 

ulceration.  The  pessary  should  be  removed  and  cleaned  as  often  as 
once  a  month ;  in  the  meantime  the  patient  should  be  instructed  to 
use  a  vaginal  douche  for  cleanliness  two  to  three  times  a  week. 
Always  before  re-inserting  the  pessary  examine  the  posterior  fornix 
through  a  speculum  to  see  that  no  pressure-sore  is  forming. 


PESSARIES. 


1  °' 
1  ■>■ 


What  are  the  operative  procedures  for  holding  a  retroverted 
uterus  in  place  after  reposition  ? 
a.  Alexander's  operation;  b.  Hysterorrhaphy ;   c.  Intra-abdom- 
inal operations  on  the  round  ligaments. 

Describe  briefly  Alexander's  operation. 

Alexander's  operation  for  shortening  the  round  ligaments  is  per- 
formed as  follows :  The  skin  about  the  pubes  is  shaved  and  prepared 

Fig.  29. 


Second  Stage :  Pessary  carried  on  by  Finger  (Hart  and  Barbour). 

antiseptically ;  the  pubic  spine  is  taken  as  the  first  landmark ;  an 
incision  is  then  made,  2  inches  long,  from  that  point  upward  and 
outward,  in  the  direction  of  the  inguinal  canal ;  the  incision  is  deep- 
ened until  the  tendon  of  the  external  oblique  is  seen ;  the  external 
abdominal  ring  is  now  visible ;  the  intercolumnar  fascia  is  cut 
through  in  the  long  diameter  of  the  ring ;  if  necessary  the  incision 
may  be  continued  up  to  the  internal  ring  ;   the  round  ligament  can 


134  ESSENTIALS   OF  GYNAECOLOGY. 

usually  now  be  seen,  with  the  genital  branch  of  the  genito-crural 
nerve  along  its  anterior  surface.  The  ligament  is  then  separated 
from  neighboring  structures  and  gently  drawn  out  a  little  to  show 
that  it  is  free.  Alexander  then  leaves  this  side  covered  with  a  clean 
sponge  and  operates  on  the  other  side  in  the  same  way.  The  uterus 
is  then  thrown  forward  by  the  sound  in  the  hands  of  an  assistant 
and  the  ligaments  drawn  out  till  they  are  felt  to  control  the  uterus ; 
the  ligaments  are  then  given  to  an  assistant  to  hold,  and  they  are 
each  sutured  with  catgut  to  the  pillars  of  the  ring ;  the  bruised  ends 
are  cut  off  and  the  wound  closed.  The  patient  is  kept  in  bed  two 
to  three  weeks,  and  wears  a  pessary  for  several  months. 

What  are  the  indications  for  Alexander's  operation? 

The  field  of  the  operation  is  very  limited.  Where  a  retroverted 
uterus  is  movable,  unaccompanied  by  disease  of  the  appendages, 
and  either  cannot,  with  comfort  to  the  patient,  be  held  in  position 
by  a  pessary,  or  the  patient  is  unwilling  to  wear  a  pessary,  Alexan- 
der's operation  may  be  employed.  Some  men  employ  it  as  a  part 
of  the  operative  treatment  of  prolapsus  uteri. 

What  are  the  advantages  of  Alexander's  operation  as  com- 
pared with  hysterorrhaphy  ? 

In  Alexander's  operation  the  uterus  itself  is  only  held  by  liga- 
ments which  normally  hold  it.  It  is  therefore  better  fitted  for 
growth  in  pregnancy  than  where  the  fundus  is  firmly  attached. 

It  is  performed  without  invading  the  peritoneal  cavity,  and  leaves 
the  patient  with  a  moderately  movable  uterus. 

What  are  the  objections  raised  to  Alexander's  operation? 

It  is  not  applicable  unless  the  uterus  is  freely  movable. 

The  ligaments  are  sometimes  difficult  to  find ;  one  or  both  may 
be  poorly  developed. 

Hernia  occasionally,  though  rarely,  occurs. 

The  round  ligaments  are  not  true  ligamentous  structures,  but 
muscular  cords,  and  it  is  doubtful  whether  they  are  to  be  considered 
as  normal  supports  of  the  uterus.  Hence,  when  tension  is  put  upon 
them,  they  are  likely  to  stretch.  The  distal  end  is  the  weaker  end 
of  the  ligaments. 

What  are  the  synonyms  of  hysterorrhaphy  ? 

Ventral  suspension,  ventrofixation,  and  hysteropexy. 


PESSARIES.  135 

Describe  briefly  the  operation  of  hysterorrhaphy  for  retro- 
versio-flexio. 

The  abdomen  is  opened  in  the  median  line  as  for  an  ovariotomy ; 
the  adhesions  binding  the  uterus  backward  are  broken  up,  the  fundus 
brought  forward  and  the  uterus  stitched  to  the  anterior  abdominal 
wall.  The  sutures  are  usually  two  in  number,  of  either  silk  or 
chromicised  catgut,  and  are  inserted  one  just  posterior  to  the  middle 
of  the  fundus  and  the  other  posterior  to  that,  so  that  when  the 
sutures  are  tied  the  uterus  will  be  slightly  anteverted.  These  sutures 
pass  through  aponeurosis,  muscle,  and  parietal  peritoneum  of  one 
side,  then  through  a  portion  of  the  fundus  of  the  uterus,  then 
through  parietal  peritoneum,  muscle,  and  aponeurosis  of  the  other 
side.  These  sutures  are  buried  in.  the  closure  of  the  abdominal 
wound. 

Another  method  is  to  pass  the  suture  through  the  entire  thick- 
ness of  the  abdominal  wall,  then  through  the  fundus  and  out  through 
the  abdominal  wall.  This  suture  can  be  removed  later  and  avoids 
the  possibility  of  later  trouble  from  a  non-absorbable  buried  suture. 

The  usual  antiseptic  dressing  is  applied.  A  pessary  is  often 
inserted  for  a  time. 

What  are  the  indications  for  hysterorrhaphy  ? 

Hysterorrhaphy  is  indicated  in  a  retro  verted  fixed  uterus,  especially 
where  pregnancy  is  improbable ;  in  a  retroverted  uterus  after  the 
removal  of  both  appendages ;  as  one  stage  in  the  operation  for  pro- 
lapsus uteri.  Kelly  says:  "Suspension  of  the  uterus  should  be 
resorted  to  only  in  cases  of  persistent  retroflexion  which  refuse  to 
yield  to  simple  plans ,  of  treatment  through  the  vagina,  and  then 
only  when  the  discomforts  of  the  retroflexion  are  sufficient  to  inter- 
fere seriously  with  health. ' ' 

What  are  the  disadvantages  of  hysterorrhaphy  ? 

Experience  shows  that  in  pregnancy  following  hysterorrhaphy  the 
portion  of  the  uterine  wall  behind  the  point  of  suture  is  that  which 
undergoes  the  chief  distention  and  thinning.  Although  obstetric 
accidents  due  to  the  operation  are  rare,  disturbances  of  parturition, 
and  even  rupture  of  the  thinned  posterior  uterine  wall,  may  occur. 

What  modification  has  Kelly  advocated  to  obviate  the  dis- 
advantages of  hysterorrhaphy? 

He  sutures  the  fundus  to  the  abdominal  wall  with  two  silk  sutures, 


136  ESSENTIALS   OF  GYNECOLOGY. 

botli  passed  through  the  posterior  aspect  of  the  uterus  behind  a  line 
connecting  the  inner  ends  of  the  Fallopian  tubes.  These  only 
include  with  the  fundus  the  parietal  peritoneum  and  subperitoneal 
connective  tissue.  The  fundus  is  not  so  firmly  secured  as  by  the 
former  method.  It  gradually  recedes  from  the  abdominal  wall  and 
is  connected  with  it  by  a  band  of  adhesions.  In  subsequent  opera- 
tions on  patients  so  treated  Kelly  has  found  this  band  measuring 
three  to  five  centimeters. 

What  is  the  chief  force  in  retaining  the  uterus  in  a  forward 
position  after  hysterorrhaphy  or  Alexander's  operation  ? 

It  is  intra-abdominal  pressure  now  brought  to  bear  on  the  posterior 
aspect  of  the  uterus. 

Describe   briefly  intra-abdominal  shortening  of  the  round 
ligaments. 

After  opening  the  abdomen  and  separating  the  adhesions,  the 
uterus  is  brought  forward  into  normal  position  and  held  there  by 
taking  up  the  slack  in  the  round  ligaments.  This  has  been  accom- 
plished in  a  great  variety  of  ways,  among  them  may  be  mentioned 
the  following :  The  round  ligaments  are  folded  upon  themselves 
and  the  folded  ligament  sutured  to  itself.  A  fold  of  the  round 
ligament  may  be  sutured  to  the  uterus.  The  ligaments  near  the 
uterine  cornua  may  be  sutured  to  the  inner  surface  of  the  abdominal 
wall.  Webster  divides  them  at  their  uterine  end,  makes  a  hole  in 
the  broad  ligament  just  under  the  Fallopian  tube,  and  through  this 
passes  the  round  ligament.  The  two  round  ligaments  are  then 
sutured  together  over  the  posterior  surface  of  the  uterus.  Gilliam 
draws  a  fold  of  each  ligament  through  a  small  hole  in  each  rectus 
muscle  and  sutures  it  there. 

Describe   the   Gilliam  operation    through  the  Pfannenstiel 
incision. 

The  Pfannenstiel  incision  is  made  as  follows :  A  transverse  in- 
cision, slightly  bowed,  with  the  convexity  downward,  is  made  about 
1J  inches  above  the  symphysis  pubis.  This  can  usually  be  brought 
into  one  of  the  natural  folds  of  the  skin.  The  incision  is  carried 
through  skin,  fat,  and  aponeurosis  covering  the  pyramidalis  and 
rectus  muscles.  The  upper  edge  of  the  aponeurosis  is  retracted 
upward,  and  thus  is  exposed  an  area  of  the  rectus  and  pyramidalis 


PROLAPSUS   UTERI.  137 

muscles.  The  pyramidalis  muscles  are  now  separated  and  the  peri- 
toneum divided  also  by  a  median  incision.  The  Gilliam  operation 
is  now  performed  as  follows  on  each  round  ligament :  A  needle 
and  suture  are  carried  under  the  round  ligament  1  to  1 J  inches  from 
the  uterus.  This  suture  is  left  long  and  not  tied,  but  simply  used 
as  a  tractor.  In  the  line  of  the  transverse  incision  a  blunt  forceps 
is  thrust  through  the  rectus  muscles  and  peritoneum  into  the  ab- 
domen, the  point  of  entrance  being  some  distance  lateral  to  the 
median  line.  The  instrument  is  opened  and  grasps  the  ends  of  the 
tractor  and  is  withdrawn  until  a  loop  of  the  round  ligament  is  drawn 
out  through  the  muscle.  When  both  ligaments  are  brought  into 
view  the  median  incision  through  peritoneum  and  muscle  is 
closed  by  sutures.  Then  the  transverse  incision  through  the  aponeu- 
rosis is  sutured  with  chromic  gut,  two  sutures  on  each  side  including 
the  round  ligaments,  so  that  the  ligament  comes  through  the  peri- 
toneum and  muscles  and  is  sutured  to  the  deep  surface  of  the  apon- 
eurosis. As  described  by  Gilliam,  the  simple  median  incision  is  em- 
ployed, and  the  ligaments  are  drawn  through  aponeurosis  as  well 
as  muscle.     Skin  and  fat  suture  completes  the  operation. 

Prolapsus  Uteri. 

What  is  meant  by  this  expression? 

Hart  and  Barbour  define  prolapsus  uteri  as  a  downward  displace- 
ment of  entire  displaceable  portion  of  pelvic  floor,  uterus,  and  ap- 
pendages past  entire  fixed  portion,  with  coincident  descent  of  small 
intestine.  It  is  not  unlike  a  hernia,  the  vagina  and  uterus  being 
considered  the  coverings  of  the  sac,  the  vulvar  orifice  the  ring 
through  which  the  hernia  protrudes,  and  the  contents  of  the  sac 
being  the  prolapsed  intestine. 

What  is  meant  by  the  "  entire  displaceable  portion  of  pelvic 
floor"? 

' '  The  entire  displaceable  portion  comprises  bladder,  urethra  and 
vaginal  walls.  It  has  resting  upon  it  the  uterus,  broad  ligament, 
Fallopian  tubes  and  ovaries. ' ' 

What  is  the  "  entire  fixed  portion  of  pelvic  floor  "  ? 

That  outside  of  the  entire  displaceable  portion,  i.  e. ,  tissue  attached 
to  the  posterior  surface  of  the  symphysis ;    all  outside  the  inner 


138  ESSENTIALS   OF   GYNAECOLOGY. 

aspect  of  the  levatores  ani ;  the  rectum  and  tissue  attached  to  the 
sacrum. 

Explain  the  function  of  the  two  segments. 

The  displaceable  portion  of  the  floor  is  also  called  the  pubic 
segment  or  the  supported  segment.  It  is  everywhere  loosely,  at- 
tached to  its  surrounding  structures. 

The  fixed  portion  is  called  the  sacral  segment  or  supporting  seg- 
ment, since  the  displaceable  portion  rests  upon  it  and  is  supported 
by  it.  This  division  of  the  pelvic  floor  structures  into  two  segments 
has  its  real  significance  from  the  behavior  of  the  two  parts  during 
labor.  The  entire  displaceable  portion  and  the  anterior  lip  of  the 
cervix  are  drawn  up  into  the  abdomen  above  the  head,  as  autopsies 
on  women  dying  in  labor  have  shown ;  the  fixed  portion  is  some- 
what displaced  downward.  The  displaceable  portion  of  the  floor 
must  of  necessity  then  be  loosely  attached  to  the  pelvic  wall  to  allow 
it  to  recede  into  the  abdomen  during  labor. 

What  are  the  degrees  of  prolapsus  uteri  ? 

According  to  Thomas  there  are  three  : — 

1.  When  the  organ  has  sunk  in  the  pelvis. 

2.  When  the  cervix  is  at  the  ostium  vaginae. 

3.  When  a  part  or  the  whole  of  the  uterus  lies  between  the  thighs. 
The  third  degree  is  sometimes  called  procidentia. 

What  is  the  etiology  ? 

The  three  elements  in  the  etiology  of  prolapse  are — 

1.  Relaxation  of  the  ligaments  of  the  uterus,  combined  with  lack 
of  tone  in  the  entire  displaceable  portion  of  the  pelvic  floor  and 
"  slackening  of  loose  tissue  around  it. " 

2.  Lack  of  support  in  the  entire  fixed  portion  of  the  pelvic  floor, 
especially  laceration  of  the  perineum. 

3.  Intra-abdominal  pressure. 

The  chief  predisposing  causes  are  parturition,  laborious  occupa- 
tions, anything  increasing  weight  of  the  uterus,  advanced  age.  Pro- 
lapse is  sometimes  produced  acutely  by  blows,  falls,  heavy  lifting, 
etc. ,  but  is  usually  the  gradual  result  of  the  three  elements  mentioned 
above. 

Give  its  pathology. 

All  the  pelvic  contents  may  prolapse  and  not  the  uterus  only. 


PROLAPSUS   UTERI.  139 

Those  cases  in  which  the  uterus  first  descends  and  is  followed 
by  the  vaginal  walls,  which  invert  as  it  descends,  are  called  pri- 
mary prolapse.  In  secondary  prolapse  the  vaginal  walls  and  struct- 
ures attached  to  them  first  descend,  and  as  they  do  so  drag  the 
uterus  after  them.  Most  commonly  the  process  begins  as  a  descent 
of  the  bladder  and  anterior  wall  of  the  vagina  in  cystocele  The 
uterus  in  its  descent  usually  follows  a  curve,  the  cervix  moves  to- 
ward the  vulva  and  the  fundus  falls  back  into  the  hollow  of  the 
sacrum.  Retroversion  must  precede  any  considerable  degree  of 
prolapse,  though  slight  prolapse  with  the  direction  of  the  uterine 
axis  unchanged  is  possible.  The  circulation  in  the  uterus  is  ob- 
structed, leading  to  swelling  of  the  organ  and  hyperplasia  of  its 
mucosa.  The  elongation  of  the  cervix  is  chiefly  due  to  swelling 
and  traction  of  vaginal  walls  upon  it,  but  to  a  less  degree^  and  in 
some  cases  only  from  an  actual  hypertrophy. 

What  is  the  relation  of  the  pubo-coccygeus  muscles  to  pro- 
lapse ? 

They  are  the  most  important  single  structure  in  guarding  the  vul- 
var orifice  against  a  hernia  through  it.  In  bad  cases  they  are  usually 
found  completely  torn  across.  We  usually  find  prolapse  asso- 
ciated with  lateral  tears  that  injure  these  muscles  rather  than  with 
median  tears,  no  matter  how  deep. 

What  are  the  symptoms  ? 

Those  of  the  acute  prolapse  are  sudden,  severe  pain,  vomiting, 
retention  of  urine  and  signs  of  peritonitis.  The  symptoms  of  the 
gradual  prolapse  are  a  dragging  sensation  in  lower  abdomen  and 
back,  and  the  discomfort  from  the  protrusion  and  excoriation  of  the 
parts  ;  difficulty  in  urination  is  sometimes  present. 

What  are  the  physical  signs  ? 

These  depend  on  the  degree  of  the  prolapse.  If  the  prolapse  is 
partial,  the  anterior  vaginal  wall  bulges  at  the  ostium  vaginae,  the 
cervix  is  lower  than  normal,  and  if  there  is  marked  laceration  of  the 
perineum  the  posterior  vaginal  wall  also  bulges.  The  uterus  becomes 
more  and  more  retroverted  as  it  sinks  in  the  pelvis.  When  the  pro- 
lapse is  complete,  the  cervix  and  more  or  less  of  the  body  of  the 
uterus  lies  outside  of  the  vulva;  the  anterior  vaginal  wall  and  part  of 
the  lower  bladder  wall  have  prolapsed  with  the  cervix;  the  posterior 


140  ESSENTIALS   OF  GYNECOLOGY. 

vaginal  wall  with  or  without  part  of  the  anterior  rectal  wall  is  also 
everted.  The  uterus  is  usually  enlarged  and  the  supravaginal  por- 
tion of  the  cervix  elongated. 

From  what  must  you  differentiate  prolapsus  uteri  ? 

1.  Hypertrophy  of  the  cervix: — 

{a)  Vaginal  portion ;  {b)  Supra-vaginal  portion ;  (c)  Intermediate 
portion. 

2.  Cystocele. 

3.  Rectocele. 

4.  Inversion  and  polypi. 

How  would  you  differentiate  prolapsus  uteri  from  a  cysto- 
cele? 

In  prolapse  the  uterus  is  sunken  in  the  pelvis  ;  in  cystocele  the 
uterus  lies  in  nearly  its  normal  position,  and  the  protruding  mass  is 
found,  by  the  introduction  of  the  sound  into  the  bladder,  to  consist 
of  the  anterior  vaginal  and  posterior  vesical  wall. 

How  would  you  differentiate  prolapsus  uteri  from  a  recto- 
cele? 

In  prolapse  the  uterus  is  sunken  in  the  pelvis ;  in  rectocele,  pure 
and  simple,  the  uterus  lies  in  nearly  its  normal  position,  and  the 
protruding  mass  is  found,  by  the  introduction  of  the  finger  into  the 
rectum,  to  consist  of  the  posterior  vaginal  and  anterior  rectal  wall. 

Both  cystocele  and  rectocele  are  common  complications  of  prolap- 
sus uteri. 

What  is  the  treatment  of  prolapsus  uteri  ? 

1.  By  pessaries ;  2.  By  operation. 

If  the  prolapse  is  slight  in  amount,  the  perineum  preserved,  and 
the  anterior  vaginal  wall  protrudes  but  a  little,  a  pessary  like  that 
of  Albert  Smith  may  suffice  to  hold  up  the  uterus.  If  this  fails, 
a  ring  pessary  will  sometimes  answer. 

The  two  most  important  points  in  the  operative  treatment  are  to 
restore  the  anteversion  of  the  uterus  and  to  repair  the  pelvic  floor. 

If  the  prolapse  is  marked,  the  following  combination  of  operations 
or  of  some  of  them  give  good  results : 

1.  Curettage  of  the  uterus ; 

2.  Amputation  of  the  cervix ; 

3.  Anterior  colporrhaphy ; 


LACERATION   OF  PERINEUM.  141 

4.  Perineorrhaphy; 

5.  Hysterorrhaphy,  or  shortening  of  the  round  ligaments. 
These  can  all  be  done  at  the  same  sitting.     In  some  cases  1 ,  2,  or 

3  may  be  omitted,  in  others  the  plastic  operations  will  suffice  without 
the  hysterorrhaphy,  but  in  a  well-marked  case  all  five  are  indicated. 

Vaginal  hysterectomy  is  very  seldom  indicated  for  prolapsus  uteri, 
the  patient's  condition  may  be  worse  after  it  than  before  it,  as  the 
vagina  inverts  and  bladder  prolapse  is  increased.  If  hysterectomy 
is  done  the  stumps  of  the  broad  ligaments  should  be  sutured  to  the 
vaginal  vault,  to  aid  in  resisting  the  tendency  to  vaginal  inversion. 

A  number  of  operations  have  been  devised  which  approximate  the 
bases  of  the  two  broad  ligaments  in  front  of  the  cervix,  the  object 
being  to  shorten  the  ligaments,  thereby  drawing  the  uterus  upward, 
and  to  throw  the  cervix  backward  into  the  sacral  hollow.  Duhrsen, 
through  an  anterior  colpotomy  wound,  ante  verts  the  fundus  to  a 
position  between  the  base  of  the  bladder  and  the  vaginal  wall,  and 
sutures  it  there,  so  that  the  fundus  is  only  covered  by  vaginal  wall. 
This  operation  would  never  be  justifiable  before  the  menopause. 


Laceration  of  Perineum  and  Relaxation  of  Vagi- 
nal Outlet. 

What  is  the  etiology  ? 

The  most  common  cause  of  laceration  of  the  perineum  is  child- 
birth, either  natural  or  instrumental ;  rarely,  however,  it  may  arise 
from  external  violence,  as  fehin^asiride^of'  some  sharp  object.  This 
occasionally  happens  to  little  children.  Relaxation  of  the  vaginal 
outlet,  aside  from  being  produced  by  these  visible  lacerations,  is 
also  caused  by  submucous  and  subcutaneous  rupture  or  overstretch- 
ing of  the  fibres  of  the  levator  ani  muscle,  or  perineal  fascia ;  this, 
too,  occurs  most  often  during  parturition. 

What  are  the  varieties  of  perineal  laceration  ? 

1.  Median.     They  may  be  : — 

a.  Incomplete,  extending  more  or  less  deeply  into  the  perineal 
body. 

b.  Oomp_lete,  extending  through  the  sphincter  ani  and  up  the 
rectum  for  a  variable  distance.  Complete  lacerations  are  less  likely 
to  be  followed  by  relaxation  and  rectocele  than  are  the  incomplete. 


142  ESSENTIALS  OE  GYNECOLOGY. 

2.  Lateral.  These  result  in  dividing  some  of  the  fibers  of  the 
levatores  ani,  first  those  fibers  that  end  at  the  rectum,  then  if  the 
tear  extends  more  deeply,  injuring  the  fibers  that  pass  back  to  the  tip 
of  the  coccyx.  The  torn  ends  of  the  muscle  retract  toward  their  in- 
sertion, and  the  lateral  sulci  of  the  vagina  are  felt  to  be  deepened. 
Such  tears  may  lie  entirely  within  the  vagina,  the  "skin  perineum  " 
remaining  intact. 

3.  Perineal  relaxation.  Cases  without  apparent  distinct  tear, 
but  with  all  their  results.  These  are  cases  where  there  has  been 
more  or  less  subcutaneous  rupture  of  levator  ani  fibres  due  to  over- 
stretching. 

What  is  the  importance  of  laceration  of  the  perineum  ? 

It  consists  in  the  fact  that  in  cases  of  marked  laceration,  the  fibres 
of  the  levatores  ani,  the  chief  support  of  the  vaginal  outlet,  are  torn; 
especially  those  fibres  which  are  attached  to  the  rectum  ;  at  the  same 
time  there  is  laceration  of  the  fibres  of  the  perineal  fascia.  These 
conditions  cause  relaxatiojua£  the  vaginal  outlet,  with  a  tendency  to 
rectocgle,  cystocele  and  prolapsus  uteri. 

If  the  laceration  is  througETthe  sphincter  ani,  incontinence  of 
faeces  usually  results. 

What  are  the  subjective  symptoms  of  laceration  of  the  peri- 
neum with  relaxation  of  the  vaginal  outlet  ? 

The  patient  usually  feels  incapacitated  for  any  great  exertion, 
complains  of  a  dragging  pain  in  the  back  and  the  feeling  of  weight 
in  the  pelvis. 

What  does  a  physical  examination  show  ? 

An  enlarged  vaginal  orifice,  cystocele  or  jrectocele  •  the  anus  may 
be  drawn  back  toward  the  tip  of  the  coccyx  by  the  sphincter  ani 
fibres  attached  to  its  tip  and  now  unopposed  by  the  torn  anterior 
fibres  of  the  levator  ani ;  the  depression  between  the  buttocks  at 
the  bottom  of  which  is  the  anus  may  be  less  deep  than  usual  owing 
to  the  relaxation  and  descent  of  the  pelvic  floor. 

How  would  you  determine  relaxation  of  the  vaginal  outlet? 

Insert  the  thumbs  or  index  fingers  into  the  vaginal  orifice  ;  sepa- 
rate the  labia  by  carrying  the  thumbs  or  fingers  backward  and  out- 
ward, at  the  same  time  telling  the  patient  to  strain ;  the  lax  condi- 


LACERATION   OF  PERINEUM.  143 

tion  of  the  outlet  will  then  be  readily  felt,  and  anterior  and  posterior 
vaginal  walls  will  be  seen  to  protrude. 

What  are  the  principal  operative  procedures  for  repair  of 
lacerated  perineum  or  relaxation  of  the  vaginal  outlet  ? 

The  three  following  operations  are  in  common  use — 

1.  Hegar's  operation. 

2.  Emmet's  operation. 

3.  The  Saenger-Tait  operation. 

Describe  the  Hegar  operation.    (Martin  suture.) 

In  this  as  in  all  perineal  operations  the  patient's  bowels  should 
be  freely  moved  and  the  vulva  shaved.  Just  previous  to  operation, 
the  vagina  and  vulva  should  be  thoroughly  cleansed  with  soap  and 
water  and  then  irrigated  with  an  antiseptic  solution.     In  the  Hegar 

Fig.  30. 

A 


denudation  which  is  triangular  in  shape  (see  Fig.  30),  three  points 
are  taken,  A.  B.  and  C.  That  which  is  to  be  the  apex  of  the  tri- 
angle, A,  is  in  the  median  line  of  the  posterior  vaginal  wall ;  this 
is  seized  with  a  bullet  forceps  or  tenaculum  and  drawn  upward  and 
forward.  The  points  B  and  0,  at  the  extremities  of  the  base  line, 
are  points  on  the  labia  majora  which  when  the  operation  is  com- 
pleted will  form  the  fourchette.  These  points  B  and  C  are  also 
seized  by  bullet  forceps  or  tenacula  and  are  drawn  apart,  thus 
facilitating  the  denudation  of  the  triangular  area  A.  B.  C. 


144  ESSENTIALS   OF  GYNECOLOGY. 

This  denuded  surface  may  either  be  closed  by  sutures  introduced 
from  side  to  side,  or  it  may  be  closed  by  a  continuous  catgut  suture 
in  tiers,  according  to  Martin.  This  is  similar  to  the  Martin  method 
of  suturing  used  in  an  anterior  colporrhaphy.     (See  further  on.) 

When  the  operation  is  completed  the  point  A  is  high  up  in  the 
vagina,  B  and  C  are  in  apposition. 

Hegar's  operation  is  well  suited  to  tears  which  are  median  or  to 
cases  where  time  is  an  important  element,  as  in  prolapse  cases  where 
the  perineorrhaphy  is  but  one  of  several  operations  performed  at  a 
sitting. 

Compare  the  methods  of  suture. 

The  Martin  suture  passed  in  a  number  of  layers  seeks  to  concen- 
trate at  the  perineum  as  much  tissue  as  possible  and  build  up  a 
rather  pyramidal  perineal  body.  The  normal  perineal  body  is  not 
of  this  form,  as  can  be  shown  if  one  passes  a  finger  into  the  rectum 
and  one  into  the  vagina  of  a  nulliparous  person.  The  supporting 
parts  of  the  perineum,  as  distinguished  from  its  mucosal  or  skin 
surfaces,  is  felt  to  be  a  small  and  rather  thin  layer  of  fascia,  not  at 
all  suggesting  the  keystone  or  pyramidal  form.  Inasmuch  as  the 
vaginal  mucosa  normally  lies  directly  on  the  pelvic  fascia,  and  since 
the  skin  perineum  is  often  intact,  best  results  will  usually  be  ob- 
tained by  using  interrupted  sutures  of  chromic  catgut  placed  within 
the  vagina,  being  careful  that  each  suture  catches  some  of  the  pelvic 
fascia  on  either  side.  By  this  method  comparatively  little  harm  is 
done  if  one  suture  gives  way,  whereas  when  continuous  sutures  are 
used  too  much  importance  attaches  to  the  holding  of  a  single  knot. 
The  same  objection  applies  to  any  method  relying  for  approxima- 
tion of  pelvic  fascia  on  one  or  two  figure-of-eight  sutures.  Most 
operators  prefer  not  to  use  buried  sutures  in  the  perineum. 

Describe  Emmet's  operation  for  restoration  of  the  perineum. 

The  patient  is  prepared  for  operation  as  usual,  with  antiseptic 
douches,  etc.  She  is  anaesthetized  and  placed  in  the  lithotomy 
position  ;  a  point  is  selected  in  the  centre  of  the  crest  of  the  bulging 
posterior  vaginal  wall,  and  a  point  on  each  labium  majus  correspond- 
ing to  the  lowest  vestige  of  the  hymen.  These  three  points  are  to 
be  brought  together  by  the  completed  operation. 

Between  the  central  point  chosen  and  the  two  lateral  are  two  triangu- 
lar areas,  with  apices  running  into  the  vaginal  sulci  on  each  side  of  the 


LACERATION   OF  PERINEUM.  145 

eolumna.  These  triangular  areas  are  first  denuded  as  follows  :  One 
tenaculum  is  inserted  into  the  central  point  chosen,  and  another  into 
one  of  the  lateral  points  ;  these  are  given  to  an  assistant,  who  draws 
the  central  point  forward  and -to  the  side  opposite  the  other  tenacu- 
lum. This  draws  the  apex  of  the  triangle  nearly  in  line  with  the  two 
tenacula  ;  a  narrow  strip  is  then  denuded  with  the  scissors  along  this 
line.  When  the  tension  is  relieved,  the  area  marked  off  is  seen  to 
be  triangular,  as  before.  The  denudation  of  this  triangle  is  then 
completed  by  long  snips  of  the  scissors.  The  lateral  point  on  the 
other  side  is  now  seized  with  the  tenaculum,  and  the  central  point 
drawn  toward  the  denuded  side  ;  this  triangle  is  denuded  as  before, 
also,  as  much  of  the  skin  surface  of  the  perineum  as  is  necessary. 
The  parts  are  now  thoroughly  irrigated  and  the  sutures  introduced 
as  follows  :  The  two  triangular  areas  are  to  be  in  the  vagina,  and  are 
sutured  with  either  silkworm  gut  or  catgut.  The  apex  of  one  tri- 
angle is  first  closed,  the  suture  entering  and  emerging  from  the 
vaginal  mucous  membrane  near  the  denuded  surface  ;  the  succeed- 
ing sutures  of  this  triangle  are  made  to  enter  the  vaginal  mucous 
membrane  on  one  side,  slant  toward  the  operator,  emerge  at  the 
centre  of  the  denuded  surface,  re-enter,  slant  away  from  the  operator 
and  emerge  from  the  mucous  membrane  of  the  other  side  a  little  in 
front  of  the  preceding  suture.  This  method  is  repeated  in  the  other 
triangle.  There  then  remains  but  a  small  external  denuded  area  to 
be  closed  ;  this  is  best  done  with  silkworm  gut.  The  upper  or  crown 
suture,  entering  the  skin  on  one  side,  passes  through  the  anterior 
extremity  of  the  eolumna  of  the  posterior  vaginal  wall,  and  emerges 
from  the  skin  on  the  other  side.  The  bowels  are  moved  about  the 
third  day  and  the  sutures  removed  on  the  eighth.  This  opera- 
tion is  best  suited  to  bilateral  tears.  The  two  triangles  denuded 
up  into  the  vagina  lie  in  two  depressions  formed  by  the  separation 
of  levator  ani  fibres  from  their  attachment.  Hence  when  the  sides 
of  these  triangles  are  brought  together  the  tendency  is  to  bring  the 
levator  ani  fibres  into  apposition  with  the  perineal  body.  Students 
find  difficulty  in  understanding  this  operation  from  written  descrip- 
tions, but  will  find  it  quite  simple  when  once  they  have  seen  the 
triangles  located  on  the  living  subject. 

Compare  the  Emmet  perineorrhaphy  with  the  Hegar. 

The  Hegar  operation  can  be  done  more  quickly  and  easily  than 
the  Emmet.  If  the  central  point  in  the  Emmet  operation  is  brought 
10 


146 


ESSENTIALS   OE   GYNECOLOGY. 


down  too  far  it  is  apt  to  intervene  between  the  lateral  portions  of  the 
pelvic  fascia,  upon  the  union  of  which  in  the  middle  line  we  chiefly 
depend  for  restoration  of  pelvic  support.  As  Kelly  does  the  opera- 
tion the  mid-point  is  left  well  inside  the  vagina.  In  the  Hegar 
operation  the  upper  limit  of  the  denudation — i.  e. ,  the  crest  of  the 
rectocele — is  made  to  recede  farther  and  farther  up  into  the  vagina  as 
the  suturing  proceeds,  instead  of  being  drawn  downward  as  in  the 
Emmet. 

Fig.  31. 


Describe  the  Saenger-Tait  operation. 

The  patient  is  prepared  for  operation  by  having  the  bowels  freely 
moved,  the  vulva  shaved,  and  an  antiseptic  vaginal  douche  given. 
She  is  then  anaesthetized  and  placed  in  the  lithotomy  position,  with 


LACERATION   OP   PERINEUM.  147 

knees  supported  by  Clover's  crutch  and  hips  resting  on  Kelly's 
perineal  pad.  The  vagina  and  vulva  are  now  scrubbed  with  soap- water 
and  irrigated  with  an  antiseptic  solution,  and  an  assistant  so  stationed 
that  he  can  allow  a  mild  antiseptic  solution  or  sterilizer!  salt  solution  to 
trickle  on  the  wound  during  the  operation.  A  tampon  is  inserted  into 
the  rectum,  the  string  left  projecting.  The  index  and  middle  fingers 
of  the  left  hand  are  now  inserted  into  the  rectum,  as  seen  in  Fig.  31 ; 
the  labia  are  separated  by  an  assistant,  the  blades  of  the  scissors  (Tait 
uses  angular  scissors  and  inserts  only  one  blade;  scissors  curved 
slightly  on  the  flat,  with  points  rather  sharp,  and  both  blades  in- 
serted, may  be  used  with  advantage)  inserted  into  the  recto-vaginal 
septum  just  in  front  of  the  anus,  and  the  vaginal  and  rectal  mucous 
membranes  separated  for  some  distance  around  the  point  of  inser- 
tion. A  horizontal  incision  is  now  made  through  the  point  of  inser- 
tion, extending  on  either  side  to  a  perpendicular  through  the  lower 
extremity  of  the  nymphse  ;  an  incision  is  made  with  the  scissors  up 
along  this  perpendicular  to  the  lower  extremity  of  the  nymphae. 
The  flap  so  marked  out  is  then  dissected  up  to  the  crest  of  the 
bulging  posterior  vaginal  wall.     See  Fig.  32. 

The  parts  are  now  freshly  irrigated,  and  the  sutures  of  silver  wire 
introduced  as  follows  :  Either  a  Peaslee's  needle  or  a  long,  straight 
needle  with  a  thread  loop  maybe  used  ;  the  sutures,  3-4  in  number, 
are  inserted  just  within  the  denuded  area  on  one  side,  and  brought 
out  just  within  the  denuded  area  on  the  other.  See  Fig.  33.  The 
tampon  is  removed  from  the  rectum,  the  sutures  twisted  up  and 
either  left  long  or  shotted  and  cut  short.  The  skin  is  now  brought 
into  apposition  by  supei-ficial  silkworm-gut  sutures  introduced  be- 
tween the  wires,  giving  the  result  seen  in  Fig.  34.  An  antiseptic 
dressing  and  a  T-bandage  are  applied,  and  the  patient  is  put  to  bed. 

The  bowels  are  moved  about  the  third  day,  and  the  sutures  re- 
moved on  the  eighth. 

Discuss  the  merits  of  the  Saenger-Tait  operation. 

The  results  of  this  operation  were  not  good.  Skin  and  vulvar 
structures  were  approximated,  but  the  efficiency  of  the  pelvic  floor 
as  a  support  was  not  improved.  The  operation  would  now  be  of 
only  historic  interest  were  it  not  that  in  recent  years  other  operators 
(Webster,  Mayo)  employed  methods  of  operating  based  on  the  flap- 
splitting  principle — i.  <■.,  separating  vagina  and  rectum — then  by 
suture  approximating  pelvic  fascia  and  muscle  between.     The  ad- 


148 


ESSENTIALS   OF  GYNAECOLOGY. 


Fig.  32. 


Fig.  33. 


LACERATION   OF  PERINEUM. 


149 


vantages  of  these  operations  are  that  they  are  quickly  performed, 
and  that  they  do  not  present  a  suture  line  in  the  vagina.     These 
advantages  will  only  have  weight  if  the  pelvic  support  can  be  as 
well  restored  as  in  the  other  method  of  operating. 
Mention  another  modification  of  operative  technique. 

Some  writers  have  suggested  that  inasmuch  as  the  restoration  of 
the  physiological  action  of  the  pelvic  floor  presupposes  a  restoration 
of  the  normal  muscular  attachments,  that  we  should  cut  down  upon 

Fig. 34. 


Fio.  35 


and  identify  the  levatores  ani  and  pass  our  sutures  through  the 
muscle  bundles.  We  see  no  reason  why  they  cannot  be  as  well 
brought  together  in  their  sheaths  of  fascia  as  denuded  of  it.  ^  If  the 
sutures  include  muscles  as  well  as  fascia,  the  muscle  within  their 
grasp  is  sure  to  atrophy.  The  more  extensive  dissection  will  cause 
longer  operation  and  greater  blood  loss. 

What  is  a  good  method  of  procedure  when  the  laceration 
extends  through  the  sphincter  ani  ? 
Thoroughly  cleanse  the  vagina  and  lower  portion  of  the  rectum. 


150  ESSENTIALS   OF  GYNAECOLOGY. 

Denude  a  V-shaped  area  with  apex  up  the  rectum,  representing 
the  torn  walls  of  the  latter,  and  with  the  arms  of  the  V  resting  on 
the  ends  of  the  divided  sphincter  ani  muscle.  The  denuded  sur- 
face had  best  be  a  little  larger  at  these  latter  points.  It  is  well  to 
dissect  out  and  identify  the  torn  ends  of  the  sphincter  to  insure  their 
being  brought  together  by  the  sutures.  Sutures  of  silkworm  gut 
or  chromicized  gut  are  now  introduced  as  seen  in  Fig.  35  with  ends 
in  the  rectum  and  tied.  The  ends  of  the  silkworm  gut  sutures  are 
left  long  and  protruding  from  the  anus.  This  repairs  the  rectal 
rent,  and  now  the  further  restoration  of  the  perineum  may  be 
accomplished  by  any  of  the  ordinary  methods  of  denudation  and 
suturing.     The  Hegar's  denudation  answers  admirably  here. 

What  are  the  disadvantages  of  this  operation  ? 

As  formerly  employed,  the  sphincter  ends  were  not  isolated,  but 
were  brought  together  with  their  surrounding  of  scar  tissue,  which 
often  resulted  in  a  cicatricial  bridge  intervening  between  the  ends 
of  the  muscle  and  somewhat  impairing  its  efficiency.  In  recent 
years,  following  the  recommendation  of  Kelly  and  others,  we  isolate 
the  muscle  ends  and  place  sutures  so  as  to  accurately  approximate 
them. 

A  suture  line  and  sutures  in  the  rectum  are  an  objection  to  this 
operation.  Infection  is  favored  by  way  of  the  rectum,  and  occa- 
sionally the  whole  perineum  will  give  way,  or  a  rectoperineal  or 
rectovaginal  fistula  result. 

What  is  Warren' s  method  of  operating  when  the  sphincter 
is  torn? 

Warren,  of  Boston,  in  1883  described  an  operation,  the  feature 
of  which  was  the  dissecting  from  above  downward  of  an  apron 
of  vaginal  mucosa,  and  turning  it  down  so  as  to  face  toward  the 
rectum.  This  mucosa  extended  beyond  the  anus,  and  allowed  the 
sphincter  to  be  sutured  over  it.  By  this  means  a  rectal  wound  and 
rectal  sutures  were  avoided.  The  only  objection  to  this  procedure 
is  that  in  some  cases  extensive  cicatrization  in  the  rectovaginal 
septum  make  it  difficult  to  construct  the  apron  and  make  it  liable 
to  slough. 

What  is  the  method  of  procedure  introduced  by  Noble  ? 

In  1902,  Noble,  of  Atlanta,  described  his  method.    With  a  knife 


LACERATION  OF  PERINEUM. 


151 


he  makes  an  incision  splitting  the  rectovaginal  septum ;  this 
incision  extends  from  one  sphincter  end  to  the  other.  The  sep- 
aration of  rectum  and  vagina  continues  upward  until  the  loosen- 
ing of  the  rectal  wall  permits  it  to  be  drawn  down  to  or  below 
the  anus,  much  as  one  loosens  and  draws  down  the  rectal  mu- 
cosa in  the   Whitehead   operation   for  hemorrhoids.      The   edge 


Fig.  36. 


of  the  mucosa  is  kept  well  outside  the  anus  and  the  sphincter 
sutured  around  it. 

Describe  the  operation  as  performed  by  Cragin. 

Cragin  also  draws  down  the  rectal  wall  till  it  protrudes  through 
at  the  anus;  the  technique  is,  perhaps,  a  trifle  simpler  than  Noble's. 
The  accompanying  drawings  illustrate  the  method.  Fig.  36  shows 
the  removal  of  a  transverse  strip  of  cicatricial  tissue,  which  at  either 
end  reveals  the  sphincter  ends. 


152 


ESSENTIALS   OF   GYNAECOLOGY. 


Fig.  37  shows  the  rectal  wall  drawn  down,  the  vaginal  wall  drawn 
Tip,  and  the  sutures  for  the  sphincter  in  place.  The  denudation  for 
a  perineorrhaphy  is  made,  and  in  Fig.  38  we  see  the  sutures  all 
inserted,  those  through  the  sphincter  being  already  tied.  As  the 
figure  shows,  the  point  that  was  formerly  at  the  apex  of  the  rectal 
tear  is  now  visible  as  a  tab  outside  the  anus. 

Fig.  37. 


Describe  the  operation  of  anterior  colporrhaphy. 

The  most  frequently  employed  operations  have  been  (1)  that  of 
Stoltz,  which  denuded  a  circular  area  on  the  anterior  vaginal  wall, 
and  then  puckered  the  area  by  putting  a  purse-string  suture  around 
its  periphery  and  drawing  it  tight.  (2)  Another  method,  formerly 
much  in  vogue,  made  an  oval  denudation  in  the  anterior  vaginal 
wall,  and  closed  the  denuded  area  by  Martin's  method  of  suture. 


LACERATION  OF  PERINEUM.  153 

This  consisted  in  placing  several  rows  of  superimposed  sutures,  each 
narrowing  the  raw  area  a  little  more  than  the  preceding.  These 
operations  have  not  proved  satisfactory.  The  former  shortened  the 
vagina;  in  neither  was  much  support  afforded,  the  sutured  area 
usually  stretching  out  again. 
We  now  employ  an  operation  based  on  different  principles.     It 

Fig.  38. 


is  not  unlike  the  Mackenrodt  operation  for  retroversion  of  the 
uterus.  The  Mackenrodt  colpotomy  incision  is  used — i.  e. ,  a  trans- 
verse incision  through  vaginal  wall  just  in  front  of  the  cervix. 
From  the  middle  of  this  and  extending  down  the  middle  of  the 
anterior  wall  of  the  vagina  an  incision  is  made  down  to  bladder  wall. 
By  dissecting  laterally  with  the  finger  and  up  along  the  cervix  the 
bladder  is  considerably  loosened  from  its  connections  to  vagina  and 
uterus,  and  pushed  upward  out  of  the  way.     Any  redundancy  of 


154  ESSENTIALS  OF  GYNECOLOGY. 

vaginal  wall  may  be  cut  away  along  the  edge  of  the  incision. 
Sutures  are  then  inserted,  beginning  at  the  posterior  end  of  the 
incision.  The  needle  is  entered  through  mucosa  on  one  side  of  the 
incision,  then  grasps  the  tissue  of  the  anterior  surface  of  the  cervix, 
and  comes  out  through  mucosa  on  the  other  side  of  the  incision. 
When  a  row  of  such  sutures  are  inserted,  the  vagina  is  in  contact 
with  the  cervix  and  lower  uterine  segment,  occupying  a  position  in 
relation  to  the  uterus  formerly  occupied  by  the  bladder.  The 
bladder  is  displaced  higher  up  on  the  uterus.  This  procedure  has  met 
with  much  greater  success  than  the  former  methods. 


Hypertrophy  of  the  Cervix. 

Give  the  varieties  and  etiology. 

Hypertrophy  of  the  cervix  may  involve  either  the  infra-vaginal 
or  supra-vaginal  portions.  Some  authorities  mention  hypertrophy 
of  the  intermediate  portion  of  the  cervix. 

Little  is  known  of  the  etiology. 

Hypertrophy  of  the  infra-vaginal  portion  is  usually  congenital. 

Hypertrophy  of  the  supra-vaginal  portion  usually  accompanies 
prolapse  of  the  uterus  or  vaginal  walls.  In  these  cases  it  is  more 
of  an  elongation  and  chronic  oedema  of  the  cervix  than  an  actual 
increase  of  cervical  tissue. 

What  are  the  physical  signs  and  symptoms  ? 

The  os  is  nearer  vulva  than  normal ;  it  may  even  project  beyond 
the  vulvar  opening. 

In  hypertrophy  of  the  infra-vaginal  portion,  the  cervix  is  long, 
usually  conical,  with  small  os  ;  the  vaginal  fornices  and  fundus  uteri 
are  in  their  normal  position.  If  the  cervix  protrudes  from  the 
vulva,  it  may  be  ulcerated,  from  friction. 

' '  In  hypertrophy  of  the  supra-vaginal  portion  both  anterior  and 
posterior  fornices  are  obliterated. ' ' 

' '  In  hypertrophy  of  the  intermediate  portion  the  posterior  fornix  re- 
mains, while  the  anterior  fornix  is  obliterated . ' '    (Hart  and  Barbour. ) 

What  are  the  symptoms  ? 

The  symptoms  of  hypertrophy  of  the  infra-vaginal  portion  are 
chiefly  mechanical : — 


STENOSIS   OF  THE  CERVIX.  155 

Leueorrhoea,  from  vaginal  irritation. 
Discomfort  in  exercise. 
Sense  of  weight  in  the  pelvis. 
Sterility. 

The  symptoms  of  hypertrophy  of  the  supra-vaginal  portion  are 
those  of  the  prolapse  of  the  uterus  or  vaginal  walls,  which  it  usually 
accompanies. 

What  is  the  treatment  of  hypertrophy  of  the  infra-vaginal 
portion  of  the  cervix  ? 

Amputation  of  the  cervix. 

The  best  method  is  probably  a  circular  amputation,  proceeding 
in  a  manner  somewhat  similar  to  that  employed  in  amputation  of 
an  extremity,  viz. ,  cutting  through  and  retracting  superficial  struc- 
tures, go  through  cervix  higher  up,  thus  making  the  portion  of 
cervix  removed  conical.  The  tissues  retract  so  that  the  stump  left 
also  appears  conical,  but  the  superficial  structures  can  easily  be 
brought  over  it.  The  vaginal  mucous  membrane  opposite  the 
uterine  canal  is  stitched  to  the  mucous  membrane  of  the  cervi- 
cal canal  both  anteriorly  and  posteriorly,  care  being  taken  to  make 
the  sutures  include  a  portion  of  the  substance  of  the  cervix  so  as 
to  fasten  the  flaps  down  to  the  stump  to  prevent  oozing  and  pocket- 
ing. At  the  sides  of  the  cervix  the  flaps  will  usually  come  into  easy 
apposition  and  should  be  sutured  together,  taking  care  as  above, 
that  the  sutures  include  the  deeper  structures  and  prevent  oozing. 
The  lines  of  suture  thus  extend  from  the  os  a  little  way  into  each 
lateral  fornix.  Before  the  cervix  is  completely  removed  a  few  of 
the  sutures  may  be  introduced  and  used  as  tractors. 

Another  very  good  method  is  that  of  Simon  and  Marckwald,  in 
which  the  cervix  is  first  divided  by  a  transverse  incision  into  an  an- 
terior and  posterior  lip ;  a  wedge-shaped  piece  is  then  removed  from 
each  (see  Fig.  39),  and  the  flaps  of  each  lip  are  brought  together 
with  sutures,  either  of  silkworm  gut,  catgut,  or  silver  wire. 

Stenosis  of  the  Cervix. 

What  is  the  etiology  ? 

It  may  be  either  congenital  or  acquired.  When  congenital,  it  is 
usually  associated  with  a  small  uterus,  long  cervix,  and  anteflexion. 
Stenosis  of  the  external  os  is  more  frequent  than  of  the  whole  canal. 


156 


ESSENTIALS  OF  GYNECOLOGY. 


Acquired  stenosis  results  from  cicatrization  following  the  use  of 
too  strong  caustics,  endocervicitis,  or  a  too  complete  closure  of  the 
cervical  canal  in  a  trachelorrhaphy. 

What  are  the  symptoms  ? 

Dysmenorrhea  and  sterility  The  stenosis  results  in  an  insufficient 
drainage  of  the  cervical  canal.  The  retained  secretion  gives  rise  to 
an  endocervicitis  which,  rather  than  the  stenosis,  is  to  be  considered 
the  direct  cause  of  the  sterility. 

Fig.  39. 


Marekwald's  method  of  splitting  the  cervix  into  an  anterior  and  posterior  lip  and 
then  uniting  cervical  to  vaginal  mucous  membrane  {Schroeder). 

What  is  the  treatment  ? 

Dilate  the  cervix  with  one  of  the  glove-stretcher  dilators  and 
maintain  the  dilatation  by  the  occasional  introduction  of  graduated 
sounds.  Iodoform  gauze  packing  may  be  used  for  the  first  few 
days  following  the  dilatation  of  the  canal. 

Laceration  of  the  Cervix. 

What  is  the  etiology  ? 

The  usual  cause  is  parturition  or  abortion  ;  it  occasionally  occurs 
as  a  result  of  mechanical  dilatation  of  the  cervix.  It  occurs  in  par- 
turition in  about  32  per  cent,  of  women ;  especially  in  tedious,  pre- 


LACERATION   OF  THE   CERVIX. 


107 


cipitate  or  instrumental  deliveries.  It  is  predisposed  to  by  a  rigid 
os,  faulty  presentation  or  condition  of  the  foetus,  premature  rupture 
of  the  membranes  and  previous  disease  of  the  cervix. 

What  is  the  pathology  ? 

The  laceration  may  be — 

1.  Complete.    Penetrating  the  whole  thickness  of  the  cervix. 

2.  Partial.     Including  cervical  mucous  membrane,  but  not  ap- 

pearing on  the  vaginal  surface. 

It  may  be — 

(a)  Unilateral  (see  Fig.  40). 

(b)  Bilateral. 

(c)  Stellate  (see  Fig.  41). 

The  unilateral  laceration  is  most  apt  to  occur  in  the  line  of  the 


Fig.  40. 


Single  Laceration.    The  flaps  are  held  apart  with  a  double  tenaculum  (Emmet). 


right  oblique  diameter  of  the  pelvis ;  i.  e. ,  either  anteriorly  and  to 
the  left  or  posteriorly  and  to  the  right,  especially  the  former.  This 
is  supposed  to  arise  from  the  greater  frequency  of  the  first  position 
of  the  vertex. 

Bilateral  lacerations  are  usually  more  dangerous  than  those  of  the 
anterior  or  posterior  lip.  because  opening  up  the  cellular  tissue  of  the 
broad  ligaments. 

Stellate  lacerations  are  more  apt  to  be  superficial. 

If  the  surfaces  of  laceration  are  kept  clean,  more  or  less  union 


158 


ESSENTIALS   OF   GYNAECOLOGY. 


will  occur.  Usually  there  is  partial  union,  with  eversion  and  pro- 
liferation of  the  cervical  mucous  membrane,  hyperplasia  of  the  con- 
nective tissue  and  proliferation  of  the  glandular  structure. 

What  are  the  complications  and  results  ? 

The  most  frequent  complications  are — 

1.  Cellulitis. 

2.  Peritonitis. 

3.  Endometritis,  especially  cervical  endometritis. 
-The  common  results  are — 

1.  Subinvolution. 

2.  Chronic  metritis. 

3.  Displacements  of  the  uterus. 

4.  Sterility. 


Fro.  41. 


Multiple  or  Stellate  Laceration  (Emmet). 

5.  Abortion. 

6.  Epithelioma. 

If  the  laceration  has  extended  through  the  anterior  fornix,  a  vesico- 
vaginal or  vesico -uterine  fistula  may  remain. 

What  are  the  symptoms  ? 

The  symptoms  are  due  to  the  inflammatory  processes  to  which  the 
laceration  gives  rise. 
The  patient  usually  complains  of  a  feeling  of  weight  in  the  pelvis ; 


LACERATION  OF  THE  CERVIX.  159 

leucorrhoea,  disturbances  of  menstruation,  especially  menorrhagia ; 
sterility;  neuralgia  and  various  reflex  neuroses,  such  as  suboccipital 
headache.  At  the  time  of  the  laceration  there  may  be  considerable 
hemorrhage. 

What  are  the  physical  signs  ? 

On  making  a  vaginal  examination  the  cervix  usually  feels  enlarged 
and  more  sensitive  than  usual ;  the  fissure  can,  as  a  rule,  be  readily 
detected  ;  also,  if  present,  the  eversion  of  the  cervical  mucous 
membrane,  which  usually  feels  velvety,  often  granular  or  cystic. 
Sometimes  the  eversion  is  so  extreme  that  one  does  not  notice  the 
fissure,  simply  feeling  the  velvety  or  granular  area  about  the  os. 
The  latter  may  be  so  patulous  as  to  admit  the  finger.  On  making 
the  bimanual  examination  the  uterus  is  often  found  enlarged  as  a 
whole  ;  cicatrices  may  be  felt  extending  from  the  laceration  into  one 
of  the  vaginal  fornices.  With  the  aid  of  the  speculum  one  sees  the 
erosion  on  one  side  of  or  surrounding  the  os,  and  by  drawing  the 
edges  of  the  laceration  together  with  tenacula  the  extent  of  the  tear 
is  visible.  Without  this  latter  procedure,  one  is  greatly  deceived, 
in  some  cases,  as  to  the  degree  of  the  injury. 

What  is  the  treatment  ? 

Opinions  differ  as  to  whether  lacerations  of  the  cervix,  unless 
accompanied  by  hemorrhage,  should  be  immediately  repaired  or  not. 
When  hemorrhage  accompanies  the  laceration,  the  cervix  should  be 
drawn  down  to  the  vulva  and  the  laceration  closed  with  silkworm 
gut  or  catgut  sutures. 

The  treatment  after  the  puerperium  is  as  follows :  The  complica- 
tions, if  present,  are  first  treated,  especially  peritonitis  or  cellulitis,  by 
counter-irritation,  hot- water  vaginal  douches,  glycerine  tampons,  etc. 

The  cervical  endometritis  is  treated  by  pricking  the  cysts,  if 
present,  and  applying  to  the  cervical  mucous  membrane  carbolic 
acid,  iodine,  silver  nitrate,  or  alumnol,  10  per  cent,  in  glycerine. 
The  corporeal  endometritis  is  treated  by  the  curette,  if  necessary, 
and  applications  as  in  cervical  endometritis. 

The  growth  of  the  squamous  epithelium  over  the  erosions  is 
stimulated  by  astringent  applications,  such  as  pyroligneous  acid. 
Under  the  above  procedures  the  uterus  often  returns  to  its  normal 
size,  and  the  symptoms  associated  with  the  laceration  disappear. 


160 


ESSENTIALS  OF  GYNECOLOGY. 


If  the  symptoms  continue  after  the  foregoing  treatment,  and 
neither  peritonitis  nor  cellulitis  is  present,  Emmet's  operation  of 
trachelorrhaphy  is  indicated.  Where  the  cervix  is  much  hypertro- 
phied  when  it  is  riddled  with  cysts,  and  therefore  is  not  fitted  to  the 
operation  of  trachelorrhaphy,  a  Schroeder's  amputation  of  the 
mucosa  may  be  substituted  or  a  circular  amputation. 


Fig.  42. 


Trachelorrhaphy  for  Bilateral  Laceration  of  the  Cervix  li  teri.    Sutures  introduced. 


Describe  briefly  the  operation  of  trachelorrhaphy. 

The  patient,  after  the  usual  preparation  regarding  bowels,  bladder, 
and  antiseptic  vaginal  douche,  is  anaesthetized  and  placed  in  the 
dorsal  position,  with  Kelly's  pad  beneath  the  hips,  and  legs  sup- 
ported with  a  leg-holder.  The  vulva  and  vagina  are  thoroughly 
scrubbed  with  soap  and  water,  and  an  antiseptic  douche  given.  The 
perineum  is  retracted  with  a  speculum ;  the  anterior  lip  of  the 
cervix  is  seized  with  a  bullet-forceps,  and  the  uterus  drawn  down 
and  steadied  by  an  assistant. 

The  edges  of  the  laceration  are  now  pared  with  scissors  or  knife, 
giving  the  denuded  area  seen  in  Fig.  42,  and  leaving  enough  mucous 
membrane  in  the  center  for  the  cervical  canal.  Care  should  be  taken 
to  excise  the  plug  of  cicatricial  tissue  at  the  angle  of  the  laceration. 


ENDOMETRITIS. 


161 


The  parts  are  now  irrigated  with  sterile  solution,  and  the  sutures  of 
silkworm  gut  or  chromicized  catgut   introduced,  usually  3-4  on  a 
side,  beginning   at    the  upper   angle.     Each  is   passed  from   the 
surface  of  the   vaginal  portion,  through  the  thickness  of  one  lip, 
emerging  in  the  edge  of  the  unclenuded  mucous  membrane  ;  thence 
is  passed  into  the  edge  of  the  unclenuded   mucous  membrane  of 
the  other  lip,  through  the  lip's  substance,  and  emerges  on  the  sur- 
face of  the  vaginal  portion.    The  other  sutures  of  the  same  side  are 
introduced  in  a  similar  manner,  care  being  taken  to  bring  the  parts 
into  close  apposition  and  leave  no  pockets.      If  the  laceration  is 
bilateral,  the  suturing  of  the  other  side  is  conducted  in  the  same 
manner.     The  parts  are  again  irrigated  and  the  sutures  tied.     A 
sterile  dressing  is  applied  to  the  vulva  and  the  patient  placed  in  bed. 
The  sutures  are  left  8-10  days  when  silkworm  gut  is  used  ;  they 
may  be  left  longer  if  the  perineum  is  repaired  at  the  time  of  the 
trachelorrhaphy. 


Endometritis. 

Define  and  give  the  varieties. 

Endometritis  is  an  inflammation  originating  in  the  lining  mem- 
brane of  the  uterus,  but  not  necessarily  confined  to  the  endo- 
metrium ;  it  usually  involves  the  muscular  wall  more  or  less  deeply, 
but  in  a  less  degree  than  the  endometrium.  Some  authors  abandon 
the  term  and  call  all  uterine  inflammation  metritis.  The  term  seems 
of  value  in  calling  attention  to  the  point  of  origin  and  greatest 
severity  of  the  inflammatory  process.  It  may  be  either  acute  or 
chronic.    Acute  endometritis  usually  involves  both  cervix  and  body. 

The  chronic  is  often  confined  to  either  cervix  or  body,  and  called 
in  the  former  case  cervical  endometritis,  endocervicitis,  or  chronic 
cervical  catarrh  ;  in  the  latter  case,  corporeal  endometritis. 

Occasionally,  chronic  endometritis  affects  the  whole  uterus. 

Acute  Endometritis. 

What  is  its  etiology  ? 

It  is  always  due  to  bacteria,  most  often  the  gonococcus  but  fre- 
quently the  pyogenic  organisms.    It  is  predisposed  to  by  traumatism, 
11 


162  ESSENTIALS   OF  GYNAECOLOGY. 

unclean  Lands  or  instruments  used  in  examinations,  catching  cold 
during  menstruation,  excessive  coitus  near  menstruation,  severe 
types  of  exanthemata,  labor,  abortion,  foreign  bodies  in  the  uterus, 
sloughing  tumors  and  polypi. 

What  are  its  varieties  ? 

1.  Saprsemic.  This  results  from  the  action  of  putrefactive  germs 
on  retained  products  of  conception  or  sloughing  tumors  in  the 
uterus. 

2.  Septic.  It  may  result  from  the  introduction  of  sounds,  from 
surgical  operations  or  other  trauma,  but  most  frequently  complicates 
childbirth  or  abortion.  Williams  gives  the  bacteria  causing  puer- 
peral infection  in  the  order  of  frequency,  as  follows :  Streptococcus, 
staphylococcus,  gonococcus,  colon  bacillus,  Bacillus  diphtherise,  Ba- 
cillus aerogenes  capsulatus,  and  Bacillus  typhosus. 

3.  Gonorrhoea!     This  is  the  most  frequent  variety. 

4.  Diphtheritic. 

5.  Exanthematous. 

What  is  the  pathology  ? 

Usually  the  endometrium  of  both  body  and  cervix  is  involved, 
but  the  former  more  than  the  latter.  The  mucous  membrane  is 
swollen  and  softened ;  extravasations  of  blood  into  it  occur ;  the  epi- 
thelium is  in  places  destroyed  and  desquamated.  Sloughing  of 
mucosa,  suppurative  inflammation  of  the  uterine  wall,  and  phlebitis 
of  broad-ligament  vessels  may  occur  in  the  septic  cases.  The  secre- 
tion is  first  serous,  later  purulent,  perhaps  bloody.  In  the  gonor- 
rhoeal type  the  process  is  more  superficial;  there  is  an  abundant 
purulent  discharge,  but  no  extensive  cellutitis,  phlebitis,  sloughing, 
or  loss  of  substance. 

What  are  the  complications  ? 

The  most  common  are — 

Vaginitis;  Urethritis;  Salpingitis;  Peritonitis;  Metritis; 
Septicaemia. 

What  are  the  physical  signs  ? 

The  cervix  is  enlarged,  soft,  and  slightly  sensitive  ;  the  endome- 
trium is  very  sensitive  to  the  sound  or  probe,  and  these  should  be 
avoided.  There  is  often  an  erosion  about  the  os,  which  is  usually 
filled  with  a  ropy  secretion.     The  cervix  sometimes  looks  and  feels 


ENDOMETRITIS. 


163 


like  that  of  early  pregnancy.     The  broad  ligaments  may  be  thick- 
ened and  tender. 

What  are  the  symptoms  ? 

These  vary  with  the  nature  of  the  infection.  In  gonorrhoea  there 
is  the  abundant  yellowish  muco-purulent  discharge  with  slight  fever, 
slight  pain  and  tenderness. 

In  the  septic  cases  there  is  the  septic  temperature  characterized 
by  great  oscillations.  The  lochia  is  suppressed  and  is  followed  by  a 
sanguino-purulent  discharge.     The  pain  in  and  about  the  uterus 

may  be  severe. 

In  the  sapremic  cases  there  is  temperature,  and  the  lochia,  if  the 
case  follows  parturition,  is  replaced  by  a  discharge  with  a  putre- 
factive odor. 
What  is  the  treatment  ? 

Acute  gonorrhceal  inflammation  is  to  be  treated  on  the  expectant 
plan,  by  rest  in  bed,  light  diet,  free  catharsis,  and  hot  vaginal 
douches.  Intra-uterine  applications  are  not  advised,  as  they  increase 
the  danger  of  extension  to  the  tubes.  When  the  condition  has 
become  chronic,  curettage  may  be  employed. 

In  the  sapremic  cases  remove  the  putrefying  material  with  finger, 
forceps  or  dull  curette  with  as  little  trauma  to  the  uterus  as 
possible. 

In  septic  cases  be  sure  the  uterus  is  empty.  Do  not  use  a  sharp 
curette.  Give  occasional  intra-uterine  douches  of  salt  solution  if 
discharge  accumulates  and  temperature  is  favorably  influenced  by 

them. 

Keep  up  the  patient's  strength  with  nourishing  food.  Alcoholic 
stimulation  will  usually  be  needed.  Temperature  is  controlled  by 
cold  sponging.  Unguentum  Crede  and  collargol  are  said  to  favor- 
ably affect  septic  processes. 

If  abscesses  form  drain  them.     Hysterectomy  is  rarely  indicated. 

Chronic  Endometritis. 

What  are  the  varieties  ? 

(a)  Chronic  cervical  endometritis. 

(b)  Chronic  corporeal  endometritis. 


164  ESSENTIALS  OF  GYNECOLOGY. 

A.   Chronic  Cervical  Endometritis. 

What  are  the  synonyms  ? 

Chronic  cervical  catarrh  and  endocervicitis. 

What  is  the  etiology  ? 

Chronic  cervical  endometritis  is  predisposed  to  by  any  low  state  of 
the  system,  from  whatever  cause  produced. 
The  most  common  exciting  causes  are — 

(a)  Laceration  of  the  cervix. 

(b)  Extension  upward  of  a  vaginitis. 

(c)  Extension  downward  of  a  corporeal  endometritis. 

(d)  Displacements  of  the  uterus,  especially  flexions. 

(e)  Stenosis  of  the  cervix. 

(/)  Traumatism,  especially  septic. 

(g)  Excessive  coitus. 

(h)   Catching  cold  during  menstruation. 

What  is  the  pathology  ? 

In  mild  cases  the  mucous  membrane  alone  may  be  involved,  but 
often  more  or  less  of  the  substance  of  the  cervix  is  affected.  In  a 
well-marked  case  the  epithelium,  glands,  and  interstitial  tissue  are 
all  involved  in  the  change. 

The  cylindrical  epithelium  of  the  canal  proliferates  and  replaces 
the  squamous  epithelium  on  the  vaginal  portion  of  the  cervix.  This 
is  especially  true  where  the  cervix  is  lacerated,  and  the  cervical 
mucous  membrane  is  everted. 

The  glands  of  the  cervix  are  hypertrophied  and  proliferated,  and 
in  addition  to  this,  according  to  Huge  and  Yeit,  the  surface  of  the 
mucous  membrane  is  thrown  into  numerous  folds,  producing  gland- 
ular recesses  and  processes,  which  may  later  form  cysts. 

The  connective  tissue  of  the  cervix  is  also  increased. 

The  reddened  areas  about  the  os,  where  cylindrical  epithelium  has 
replaced  the  squamous,  and  the  glandular  structure  has  increased, 
are  called  erosions,  sometimes  wrongly  spoken  of  as  "  ulcerations. ' ' 

What  are  the  so-called  cervical  erosions  ? 

The  term  has  been  applied  to  a  number  of  distinct  pathological 
conditions : 

1.  Small  ulcers  without  epithelial  covering ;  these  are  rare. 


ENDOMETRITIS.  165 

2.  A  congenital  ectropion  of  the  uterine  mucosa. 

3.  Pseudo-erosions.  They  are  covered  by  a  single  layer  of  cylin- 
drical epithelium  and  are  due  to  two  distinct  processes :  First,  there 
may  be  an  outgrowth  of  the  mucosa  of  the  cervical  canal  over  the 
exposed  portion  of  the  cervix,  gradually  pressing  back  the  squamous 
epithelium  from  the  external  os.  These  heal  by  a  reversed  process, 
i.  e.,  a  proliferation  of  the  squamous  epithelium,  causing  a  receding 
of  the  cylindrical. 

Second,  the  irritation  of  secretions  ma}'  cause  a  maceration  and 
desquamation  of  the  superficial  squamous  cells  of  the  cervix,  leaving 
exposed  the  deeper  cylindrical  ones.  Such  erosions  appear  as  red 
spots  scattered  over  the  cervix.  They  heal  by  a  metaplasia  of  their 
epithelium. 

They  are  classified  as  simple,  papillary,  and  cystic. 

What  are  the  physical  signs  of  chronic  cervical  endome- 
tritis? 

In  nulliparae  the  cervix  may  feel  normal,  save  a  little  swollen  and 
sensitive  ;  sometimes  the  neighborhood  of  the  os  has  a  granular  or 
velvety  feel. 

In  multiparae,  especially  where  the  cervix  is  lacerated,  the  gran- 
ular area  about  the  os  is  larger,  and  small  cysts  in  greater  or  less 
numbers  can  usually  be  felt. 

What  are  the  symptoms  ? 

The  characteristic  symptom  is  the  leucorrhoea ;  this  may  irritate 
the  vulva,  causing  pruritus. 

Pain  in  the  back  and  loins,  especially  on  exertion,  is  usually  present, 
but  may  be  slight. 

Other  symptoms  are  disturbances  of  menstruation,  especially  men- 
orrhagia,  sterility  and  reflex  neuroses. 

What  is  the  treatment  ? 

Attend  to  the  general  health  and  remove,  as  far  as  possible,  the 
causes  of  the  endometritis. 

In  mild  cases,  especially  in  nulliparae,  use  hot-water  vaginal 
douches  containing  an  astringent,  as  sulphate  of  zinc  3j-Oj. 

If  more  severe,  remove  the  ropy  mucus  from  the  canal  with  a 
large-mouthed  syringe  and  apply  iodized  phenol. 

When  the  cervix  is  cystic  or  much  congested,  prick  the  cysts  or 


166 


ESSENTIALS   OF  GYNAECOLOGY. 


scarify  the  cervix.  The  use  of  the  actual  cautery  point  has  been 
recommended. 

If  the  above  treatment  fails,  dilate  the  cervix  and  curette  thor- 
oughly and  drain  the  uterus  with  iodoform  gauze. 

Schroeder's  operation  consists  in  dividing  the  cervix  into  an  ante- 
rior and  posterior  lip,  excising  the  mucous  membrane  by  a  Y-shaped 
incision  (see  Fig.  43),  and  turning  in  and  uniting  the  lips  as  seen  in 
Fig.  44. 

When  the  cervix  is  badly  lacerated  trachelorrhaphy  is  indicated. 

B.    Chronic  Corporeal  Endometritis. 

What  is  the  etiology  ? 

It  sometimes  follows  the  acute,  more  often  begins  as  chronic. 

Fig.  44. 


Schroeder's  excision  of  the  cervical  mucous  membrane  in  cervical  catarrh. 
Fig.  43.  Line  of  incision  in  mucous  mem-    Fig.  44.  Mucous  membrane  "excised  and 
brane.  flap  be  turned  in  on  ab  (Schroeder). 


The  most  common  causes  are — 

1 .  Parturition,  especially  when  the  secundines  are  not  thoroughly 
removed. 

2.  Displacements. 

3.  Traumatism,  especially  septic. 

4.  Tumors,  especially  fibroids  and  polypi. 

5.  Excessive  coitus. 

6.  Extension  of  inflammation  from  the  cervix. 

7.  Chronic  metritis. 


ENDOMETRITIS.  167 

What  is  its  bacteriology? 

The  majority  of  cases  are  not  bacterial  in  origin.  An  examina- 
tion of  the  endometrium  and  secretion  shows  no  bacteria  except 
gonococci  occasionally. 

What  is  the  pathology  ? 

The  term  chronic  endometritis  as  here  used  is  a  clinical  one  and 
covers  two  distinct  processes  : 

1.  A  chronic  interstitial  inflammation  having  the  features  of  a 
chronic  inflammation  elsewhere,  i.e.,  a  proliferation  of  the  connective- 
tissue  stroma  cells.  Glandular  changes  are  secondary.  They  may 
be  dilated,  compressed  or  diminished  in  number,  due  to  the  pressure 
of  the  new  connective  tissue.  It  may  finally  become  an  atrophic  en- 
dometritis.  Long-continued  gonorrhceal  infection  is  a  frequent  cause. 

.  2.  Hyperplasia  of  the  endometrium.  This  is  what  is  commonly 
meant  by  the  term  chronic  endometritis.  This  is  not  a  true  inflam- 
mation, nor  due  to  bacteria,  but  the  result  of  congestion  and 
chemical  irritation.  The  hyperplasia  primarily  affects  the  glands. 
They  may  be  increased  in  length  and  tortuous,  penetrating  the 
mucosa  in  corkscrew  fashion.  They  are  frequently  dilated  and  may 
form  cysts.     Many  new  ones  may  be  formed. 

If  all  portions  of  the  endometrium  are  equally  involved,  then  it  is 
uniformly  thickened  and  smooth.  Often  this  is  not  the  case,  and 
the  unequal  involvement  of  different  portions  of  endometrium 
results  in  the  formation  of  ' '  uterine  fungosities  ' '  and  ' '  villous  endo- 
metritis." 

In  some  cases  stroma  and  glands  are  both  affected. 

Chronic  corporeal  and  chronic  cervical  endometritis  are  often 
associated. 

What  are  the  symptoms  of  chronic  corporeal  endometritis  ? 

(a)  Leucorrhcea. 

(h)  Menstrual  disturbances,  especially  menorrhagia. 

(c)  Dysmenorrhcea. 

(d)  Pain  in  back  and  pelvic  region. 

(e)  Sterility. 
(/)  Abortion. 

[g)  Reflex  neuroses. 


168  ESSENTIALS  OF  GYNECOLOGY. 

What  are  the  physical  signs  ? 

On  bimanual  examination  the  uterus  is  usually  found  a  little 
enlarged ;  perhaps  a  little  tender. 

The  sound,  on  introduction,  shows  the  cavity  enlarged,  and.  usually 
detects  irregularities  in  its  mucous  membrane  ;  it  frequently  causes 
slight  bleeding. 

What  are  common  complications  ? 

Metritis. 

Salpingitis. 

Peritonitis. 

Displacements. 

Vaginitis. 

What  is  the  treatment? 

1.  Prophylactic. — Be  careful  that  the  uterus  is  thoroughly  emp- 
tied after  labor  or  abortion.  Avoid  exposure  during  menstruation. 
Observe  strict  cleanliness  and  antisepsis  in  the  use  of  uterine  in- 
struments. 

2.  Tonics,  laxatives,  change  of  air,  and  regulation  of  mode  of  life 
are  often  of  value. 

3.  Remove  the  cause,  such  as  displacements  and  tumors,  and 
attend  to  any  peri-uterine  inflammation. 

4.  The  fluid  extracts  of  ergot  and  Hydrastis  canadensis  check  the 
flow  and  act  as  a  uterine  tonic  when  given  in  doses  of  fifteen  drops 
of  each  three  times  a  day. 

5.  Proper  drainage  of  the  uterus  will  call  for  dilation  of  the  cervix 
or  correction  of  flexions. 

6.  Especially  when  associated  with  cervicitis,  hot  douches  and 
cervical  depletion  with  glycerine  tampons  and  scarification  of  the 
cervix  will  give  considerable  relief. 

7.  Applications  at  intervals  of  iodized  phenol  was  formerly  much 
advocated,  but  have  now  been  largely  replaced  by  curettage.  Ap- 
plications of  formalin  have  recently  been  recommended. 

8.  When  hyperplasia  of  the  endometrium  is  detected,  if  no  acute 
inflammation  is  present  in  the  neighborhood,  dilate  the  cervix 
and  curette  the  uterus  under  antiseptic  precautions  ;  wash  out  the 
uterus  with  a  hot  aseptic  solution,  making  use  of  a  double-current 
catheter.  The  curetting,  if  thorough,  is  best  done  under  anaesthesia. 
It  is  well  to  confine  the  patient  to  bed  for  a  week,  and  occasional 


ENDOMETRITIS.  169 

applications  of  iodized  phenol  to  the  endometrium  may  be  necessary. 
Packing  the  uterus  with  iodoform  gauze  for  twenty- four  hours  after 
the  curetting  is  often  of  value  to  check  bleeding,  maintain  dilation 
or  stimulate  uterine  contraction. 

9.  In  the  chronic  interstitial  or  atrophic  endometritis  curettage  is 
much  less  valuable,  but  the  patency  of  the  cervix  must  be  main- 
tained by  the  use  of  sounds  or  glove-stretcher  dilators. 

What  are  the  indications  for  curettage  of  the  uterus  ? 

Hyperplastic  endometritis. 
Polypi. 

Retained  secundines. 

In  malignant  disease  for  the  control  of  bleeding. 
For  diagnosis,  having  the  currettings  submitted  to  microscopical 
examination. 

How  and  for  what  purpose  are  uterine  curettings  examined  ? 

Clinical  experience  often  enables  one  to  make  a  fairly  certain 
diagnosis  from  the  macroscopic  appearance  of  currettings,  hyper- 
plastic or  normal  endometrium  being  distinguished  from  chorionic 
tissue  or  malignant  growths  with  ease  in  the  majority  of  cases. 
Under  the  microscope  we  are  able,  as  a  rule,  to  recognize  the  fol- 
lowing conditions  of  the  mucosa :  oedema,  acute  inflammatory 
changes,  hypertrophy  and  hyperplasia  of  glands,  increase  of  inter- 
stitial tissue,  vascular  engorgement,  carcinoma  or  sarcoma.  Preg- 
nancy present  or  recently  terminated — either  uterine-  or  tubal — may 
be  diagnosed  from  the  recognition  of  any  of  the  following : 
Decidual  cells,  the  glandular  changes  characteristic  of  the  spongy 
layer  of  the  decidua,  foetal  elements,  such  as  villi,  syncytium,  or 
Langhans'  cells.  At  times  small  islands  of  degenerated  decidual 
cells  are  retained  in  the  mucosa,  and  characterize  the  picture  of 
"endometritis  post  abortum."  Exfoliative  endometritis  exhibits 
changes  in  the  mucosa  strongly  simulating  the  early  changes  of  the 
compact  layer  of  the  decidua  of  pregnancy.  A  knowledge  of  the 
normal  structures  of  the  uterine  mucosa  must  precede  an  ability  to 
diagnose  its  diseases.  This  includes  recognition  of  the  varieties  of 
epithelial  covering,  forms  of  cervical  and  corporeal  glands,  their 
relation  to  the  muscularis,  and  the  age  changes  and  modifications 
due  to  pregnancy. 


170  ESSENTIALS   OF  GYNECOLOGY. 

Metritis. 
Describe  and  give  the  varieties. 

Metritis  is  an  inflammation  of  the  parenchyma  of  the  uterus,  as 
distinguished  from  that  of  its  mucous  lining  or  serous  covering. 
The  two  varieties  are  the  acute  and  chronic. 

Acute  Metritis. 
What  is  the  etiology? 

Acute  metritis  rarely  if  ever  exists  as  an  independent  condition  ; 
it  is  almost  always  associated  with  an  endometritis  or  peritonitis ; 
especially  the  former. 

The  chief  causes  are — 

1.  Septic  infection  during  or  soon  after  labor,  abortion,  or  opera- 
tion ;  2..  Gonorrhoea. 

Acute  metritis  occasionally  arises  from  exposure  to  cold  during  men- 
struation or  sexual  excess,  but  these  usually  first  produce  endome- 
tritis, secondarily  metritis. 

What  is  the  pathology  ? 

The  uterus  is  enlarged,  especially  antero-posteriorly,  infiltrated 
with  serum,  soft  and  tender.  The  endometrium  is  also  thickened 
and  congested.  The  peritoneal  investment  is  often  covered  with 
lymph.  "  Microscopically  the  muscular  bundles  are  infiltrated  with 
pus  corpuscles  "  (Hart  and  Barbour).  Circumscribed  abscesses  oc- 
casionally, though  rarely,  occur  in  the  uterine  walls.  These  often 
prove  fatal,  but  sometimes  are  absorbed,  sometimes  become  encap- 
sulated and  cheesy,  and  sometimes  empty  into  the  uterus,  bladder, 
rectum,  vagina,  intestines,  peritoneum,  or  through  the  abdominal 
walls. 

Acute  metritis  may  resolve  at  the  end  of  a  week  ;  it  may  pass  into 
the  chronic  form  ;  if  a  result  of  puerperal  infection,  it  is  often  fatal. 

What  are  the  symptoms? 

They  usually  resemble  those  of  acute  endometritis,  but  are  more 
severe.  The  disease  is  often  ushered  in  with  a  rigor ;  temperature 
and  pulse  rise ;  there  is  pain  in  the  hypogastrium  and  in  pelvis. 
The  uterus  is  very  tender  on  pressure  ;  there  is  nausea,  usually  vesi- 
cal and  rectal  tenesmus,  and  menstruation,  as  a  rule,  is  disturbed, 
sometimes  suppressed  ;  more  often  menorrhagia  is  present. 


METRITIS.  171 

What  is  the  treatment  ? 

If  due  to  sepsis,  try  to  remove  the  cause ;  giving,  if  necessary, 
intra-uterine  irrigations  of  bichloride  (1-5000).  Keep  the  patient 
quiet  in  bed ;  apply  poultices  or  turpentine  stupes  to  the  hypogas- 
trium ;  if  temperature  is  very  high,  use  the  ice  coil.  Empty  the 
bowels  with  saline  cathartics  ;  if  pain  is  very  severe,  allow  opium  by 
suppository.  Later,  employ  long  hot-water  douches  and  glycerine 
tampons.  When  intramural  abscesses  form,  hysterectomy  may  be 
necessary. 

Chronic  Metritis. 

What  are  common  synonyms? 

Areolar  hyperplasia  (Thomas).  Chronic  parenchymatous  inflam- 
mation of  the  womb  (Scanzoni).  Diffuse  interstitial  metritis  (Noeg- 
gerath). 

What  is  the  etiology  ? 

According  to  Hart  and  Barbour,  the  causes  may  be  divided  as 
follows : — 

(a)  Causes  which  operate  through  interference  with  the  normal 
involution  of  the  puerperal  uterus. 

(b)  Causes  which  operate  through  the  production  of  repeated  or 
protracted  congestion  of  the  uterus. 

(J.)  Frequent  causes  of  subinvolution  are — 

1.  Retained  secundines. 

2.  Laceration  of  the  cervix. 

3.  Pelvic  inflammation  following  parturition. 

4.  Rising  too  soon  after  parturition. 

5.  Non-lactation. 

6.  Repeated  miscarriages. 

(B)  Causing  repeated  or  protracted  congestion  are  the  following — 

1.  Chronic  endometritis. 

2.  Displacement  of  the  uterus. 

3.  Tumors  near  the  uterus. 

4.  Chronic  pulmonary,  cardiac,  hepatic  or  nephritic  disease. 

5.  Excessive  coitus. 

Chronic  metritis  sometimes  follows  the  acute  but  usually  begins  as 
chronic. 


172  ESSENTIALS   OF  GYNECOLOGY. 

What  is  the  pathology  ? 

The  pathological  changes  may  be  divided  into  three  stages— 
1.  Hypersemic;  2.  Hyperplastic;  3.  Sclerotic. 

In  the  first  or  hypereemic  stage  the  uterus  is  enlarged,  soft,  tender, 
and  contains  more  blood  than  normal. 

In  the  second  or  hyperplastic  stage  there  is  an  increase  of  the 
intermuscular  connective  tissue,  with  or  without  a  slight  increase  of 
the  muscular  tissue.  The  vascularity  is  decreased  by  the  growth  of 
connective  tissue  around  and  compressing  the  blood  vessels. 

The  third,  or  sclerotic  stage  is  a  result  of  the  former,  the 
uterus  becoming  more  dense,  less  and  less  vascular  and  finally 
atrophied. 

What  are  the  symptoms  ? 

Most  of  the  symptoms  are  either  due  to  the  increased  size  of  the 
uterus  or  to  the  complicating  endometritis.  The  symptoms  usually 
date  from  parturition  or  abortion.     The  following  are  common — 

A  feeling  of  weight  in  the  pelvis. 

Pains  radiating  to  the  back,  limbs  and  different  parts  of  the  body. 

Irritability  of  bladder  and  rectum. 

Leucorrhoea. 

Menstrual  disturbances,  especially  menorrhagia,  due  to  the  endo- 
metritis. 

Abortion  in  the  early  stages. 

Sterility,  later. 

Reflex  neuroses. 

What  are  the  physical  signs  ? 

The  uterus  in  the  early  stages  is  uniformly  enlarged,  soft  and 
tender  ;  later  harder,  and  in  the  late  stages  irregularities  of  shape 
may  be  detected.  The  canal  is  enlarged  in  all  its  dimensions  and 
the  sound  passes  easily.  The  os  is  usually  patulous ;  the  cervix 
may  be  large  and  nodular. 

What  are  common  complications  of  chronic  metritis  ? 

(a)  Chronic  endometritis. 

(b)  Salpingitis. 

(c)  Peritonitis. 

(d)  Ovaritis. 

(e)  Vaginitis. 

(/)  Displacements. 


ATROPHY  OP  THE  UTERUS.  17o 

What  is  the  treatment  of  chronic  metritis  ? 

1.  Prophylactic. — Care  during  and  after  confinement. 

2.  Curative. — 

First  treat  the  complications,  if  present,  especially  endometritis 
and  displacements,  in  the  usual  manner.  Attend  to  the  general 
health,  bowels,  exercise,  etc.  Let  the  patient  rest  a  part  of  each 
day,  especially  at  menstruation ;  limit  coitus.  Weir  Mitchell's 
treatment  of  rest,  over-feeding  and  massage  is  sometimes  of  value. 

Local  treatment. — Prolonged  hot- water  vaginal  douches;  glycer- 
ine or  boroglyceride  tampons ;  tincture  of  iodine  to  cervix  and  fornices 
of  the  vagina  ;  scarification  of  the  cervix  with  Buttle' s  spear. 

Emmet's  operation  of  trachelorrhaphy,  or  amputation  of  the 
cervix  by  the  Simon  and  Marckwald  method  is  sometimes  indicated. 

Atrophy  of  the  Uterus. 

What  is  the  etiology  ? 

It  is  the  natural  condition  after  the  menopause,  and  is  produced 
artificially  by  the  removal  of  ovaries  and  tubes.  It  occasionally 
occurs  as  the  result  of  a  too  forcible  curettage.  It  is  sometimes 
associated  with  phthisis  and  other  exhausting  diseases.  It  occurs  as 
a  superinvolution  after  childbirth,  especially  as  a  result  of  metritis, 
peritonitis,  ovaritis  or  salpingitis,  or  from  prolonged  lactation.  This 
superinvolution  is  the  variety  of  most  importance. 

What  are  the  symptoms  ? 

Amenorrhoea. 
Sterility. 
Reflex  neuroses. 

What  are  the  physical  signs  ? 

The  uterus  is  small,  both  in  body  and  cervix,  and  the  canal  is 
shortened. 

What  is  the  treatment  ? 

Attend  to  the  general  health. 

Before  the  menopause,  galvanism  of  the  uterus  and  ovaries  may 
be  tried. 
The  treatment  is  generally  unsatisfactory. 


174 


ESSENTIALS   OF  GYNECOLOGY. 


Fibroid  Tumors  of  the  Uterus. 

What  are  common  synonyms  ? 

Fibro-myomata  and  myomata.     Strictly  speaking,  fibro-myomata 
is  the  more  correct  designation,  as  the  tumors  are  composed  of  both 


Fig.  45. 


im.  Interstitial  fibroids. 
sm.  Submucous.    (Schroeder.) 


fibrous  and  muscular  tissue.     They  are  to  be  classed  as  benign 
growths. 

What  is  the  etiology  ? 

Little  is  known  of  the  cause  of  fibroids.  They  are  much  more 
common  in  the  African  than  in  the  white  race  ;  are  most  frequently 
found  between  the  ages  30-45,  and  are  said  to  be  more  common  in 


FIBROID  TUMORS   OF  THE  UTERUS.  175 

married  than  in  unmarried  women.      They  rarely,  if  ever,  begin 
before  puberty,  and  never  after  the  menopause. 

What  is  their  structure  ? 

Fibroids,  or  fibro-myomata  of  the  uterus,  are  tumors  composed  of 
both  fibrous  and  muscular  tissue,  either  of  which  may  predominate 
over  the  other.     The  fibrous  tissue  is  usually  in  excess. 

Those  composed  chiefly  of  fibrous  tissue  are  usually  more  or  less 
encapsulated,  of  slow  growth,  and  chiefly  of  the  subperitoneal  variety. 

Those  composed  chiefly  of  muscular  tissue  are  rare,  not  encapsu- 
lated, and  are  of  rapid  growth. 

They  derive  their  blood-supply  from  a  network  of  vessels  in  their 
capsules,  the  central  portions  being  without  large  vessels. 

What  are  their  situations  ? 

They  are  much  more  frequent  in  the  body  of  the  uterus  than  in 
the  cervix.  They  are  most  often  found  on  the  posterior  wall  or 
fundus,  next  in  frequency  on  the  anterior  wall,  rarely  on  the  lateral 
walls.  The  soft,  rapidly  growing  fibroids  are  more  frequent  in  the 
fundus. 

The  tumors  usually  begin  in  the  substance  of  the  uterine  walls ; 
they  may  continue  their  growth  there ;  may  extend  into  the  uterine 
cavity,  lifting  up  the  mucous  membrane,  or  outward,  lifting  up  the 
peritoneum.     Hence  the  three  varieties  : — 

1.  Interstitial. 

2.  Submucous. 

3.  Subperitoneal. 
Describe  the  three  varieties. 

The  interstitial  or  intramural  fibroids  (see  Fig.  45)  are  usually 
multiple  and  are  situated  in  the  substance  of  the  uterine  wall. 
The  submucous  fibroid  (see  Fig.  46)  may  be  either  sessile  or 
attached  by  a  long  pedicle.  In  the  latter  case  it  is  called  a  fibrous 
polypus. 

The  subperitoneal  or  subserous  fibroids  (see  Figs.  47  and  48)  are 
often  multiple  ;  may  be  sessile  or  pedunculated  ;  may  grow  upward 
into  the  abdominal  cavity  and  draw  uterus  up,  or  grow  downward 
into  the  pelvis,  and  perhaps  become  incarcerated.  They  may  form 
adhesions  with  other  organs,  get  their  nutrition  through  the  adhe- 
sions, and  become  detached  from  the  uterus.  These  are  the  most 
fibrous,  least  vascular,  and  slowest-growing  fibromyomata. 


176 


ESSENTIALS   OF  GYNAECOLOGY. 


What  changes  may  occur  in  fibroids  ? 

1.  They  may  undergo  softening  due  to  oedema  or  myxomatous 
degeneration,  rarely  fatty  degeneration.  By  this  softening  fibro- 
cysts  may  be  formed. 

2.  They  may  undergo  hardening,  due  to  (a)  atrophy,  especially 
after  the  menopause,  or  removal  of  ovaries  and  tubes.  The  mus- 
cular tissue  degenerates,  and  the  fibrous  tissue  contracts,  (b)  Calci- 
fication, with  the  deposit  of  lime  salts,  beginning  usually  in  the  centre, 
sometimes  at  the  periphery. 


Fig.  46. 


Fig.  47. 


Submucous  fibroid.     (Schroeder.) 


Subperitoneal  Fibroid. 


3.  They  may  suppurate.  This  occurs  most  often  in  submucous 
fibroids,  especially  after  instrumental  traumatism  ;  rarely  in  the 
subperitoneal  variety  after  torsion  of  the  pedicle. 

4.  Submucous  fibroids  may  become  more  and  more  pedunculated, 
forming  polypi.  They  are  sometimes  extruded  from  the  uterus. 
Sometimes  the  capsule  ruptures,  and  spontaneous  enucleation 
occurs. 

5.  Cysts  are  formed  by  the  softening  of  tissue  and  by  the  dilation 
of  lymph-spaces. 


FIBROID   TUMORS   OF   THE   UTERUS.  177 

6.  Fibromyomatous  uteri  are  occasionally  the  seat  of  carcinoma 
of  their  mucosa. 

7.  The  fibroid  nodules  occasionally  undergo  a  sarcomatous  trans- 
formation. 

8.  The  subperitoneal  ones  alone  or  with  the  uterus  may  undergo 
axial  rotation.  Minor  degrees  of  this  are  quite  common.  When 
the  rotation  occurs  suddenly,  and  through  a  considerable  arc,  there 
may  be  pain,  shock,  and  increase  of  size  of  the  tumor,  due  to  inter- 
stitial hemorrhages. 


Fig.  48. 


Subperitoneal  Fibroid. 

What  changes  occur  in  the  uterus  ? 

The  muscular  wall  hypertrophies  especially  in  the  submucous  or 
interstitial  varieties.  The  mucous  membrane  also  hypertrophies, 
both  in  glands  and  connective  tissue.  Over  the  tumor  the  mucous 
membrane  is  thin  and  sometimes  ulcerates.  The  uterine  hemor- 
rhages come  chiefly  from  the  hyperplastic  areas. 

Changes  in  the  position  of  the  uterus  are  often  produced : — 

1.  It  may  be  drawn  up  into  the  abdomen. 

2.  It  may  be  prolapsed. 

3.  It  may  be  inverted,  especially  from  submucous  fibroids  attached 
to  the  fundus. 

Describe  briefly  fibroids  of  the  cervix. 

They,  too,  may  be  either  interstitial,  submucous  or  subperitoneal ; 
they  are  usually  hard  and  single. 
12 


178  ESSENTIALS   OF   GYNAECOLOGY. 

The  subperitoneal  often  grow  out  between  the  folds  of  the  broad 
ligament. 

The  submucous  and  interstitial  are  apt  to  become  pedunculated 
and  form  polypi.  The  interstitial  fibroid  of  the  cervix  is  sometimes 
mistaken  for  inversion  of  the  uterus. 

What  are  the  symptoms  of  fibroid  tumors  of  the  uterus  ? 

1.  Hemorrhage. — First,  menorrhagia,  later  metrorrhagia ;  delayed 
menopause  ;  these  occur  especially  in  the  submucous  variety. 

2.  Pain. — (a)  Dysrnenorrhcea,  chiefly  in  the  submucous  variety. 

(b)  Pain  due   to  pressure  on  the  pelvic  nerves  or  to 
peritonitis  around  the  tumor. 

3.  Symptoms  due  to  pressure  : — 

On  bladder,  causing  : — 

Irritability. 
Retention. 
Cystitis. 
On  urethra,  causing : —        Difficulty  in  micturition. 

Perhaps  retention. 
On  ureter,  causing : —         Hydronephrosis,  pyonephrosis,  or  pos- 
sibly chronic  nephritis. 
On  rectum,  causing : —         Constipation. 

Diarrhoea. 

Sometimes  tenesmus. 
.Rarely  complete  obstruction. 
On  pelvic  nerves,  causing :  —Neuralgia. 

Numbness. 
On  veins,  causing :  —         Varicosities  of  the  legs. 

Haemorrhoids. 

4.  Sterility. 

5.  Abortion. 

What  are  the  physical  signs  ? 

Except  in  the  case  of  some  subperitoneal  fibroids,  the  uterus  is 
enlarged. 

If  within  reach,  a  tumor  is  felt,  harder  than  the  muscular  sub- 
stance of  the  uterus,  and  movable  with  the  uterus  unless  it  is  attached 
with  a  very  long  pedicle. 

If  it  is  a  small  fibroid  in  the  cervix  it  may  bulge  into  the  vagina  and 
resemble  inversion  of  the  uterus. 

If  it  is  a  submucous  fibroid,  high  up  in  the  uterus,  the  sound  may 


FIBROID   TUMORS   OF  THE   UTERUS.  179 

detect  it,  but  often  it  is  necessary  to  dilate  the  cervix  and  introduce 
the  finger. 

If  it  is  subperitoneal  and  on  the  anterior  wall,  a  hard  mass  is  felt  in 
the  anterior  fornix  moving  with  the  uterus ;  the  fundus  may  be  felt 
behind  it,  and  the  sound  on  introduction  does  not  pass  into  it. 

If  on  the  posterior  wall,  a  hard  mass  is  felt  in  the  posterior  fornix  ; 
the  bimanual  shows  fundus  in  front  of  it,  and  the  sound  passes  in 
front  of  it. 

If  it  is  a  large  fibroid  extending  into  the  abdomen,  it  is  flat  on  per- 
cussion unless  intestine  overlies  it ;  auscultation  may  detect  the  ute- 
rine souffle,  especially  at  the  sides,  and  the  mass  seems  to  belong  to 
the  uterus. 

What  is  their  bearing  upon  pregnancy  ? 

They  may  cause  sterility  or  abortion.  They  are  apt  to  take  on 
rapid  growth  as  pregnancy  progresses.  The  amount  of  hindrance 
to  labor  depends  more  on  their  position  than  size.  A  fibroid  may 
interfere  with  uterine  contraction  and  thus  be  a  cause  of  postpartum 
hemorrhage.  On  the  other  hand,  they  may  largely  involute  with 
the  uterus. 

From   what   must   you    differentiate    a   fibroid   tumor   of 
the  uterus? 

Chronic  metritis. 
Flexions  of  the  uterus. 
Pregnancy. 
Ovarian  cyst. 
Ectopic  gestation. 
Pelvic  haematocele. 
Inflammatory  deposits. 
Inversion  of  the  uterus. 

How  would  you  differentiate  a  small  fibroid  tumor  from 
chronic  metritis  1 

Small  Fibroid  vs.  Chronic  Metritis. 

Enlargement  not  uniform,  usually      Enlargement  uniform. 

hard  irregularities. 
Less  sensitive.  More  sensitive. 

Os  usually  unaffected.  Os  usually  everted. 

Both  conditions  may  co-exist. 


180  ESSENTIALS   OF   GYNAECOLOGY. 

The  differential  diagnoses  between  fibroids  and  flexions  of  the 
uterus  have  already  been  given  (see  page  124,  Fig.  23). 

How  would  you  differentiate  a  fibroid  tumor  from  preg- 
nancy ? 

Fibroid  Tumor  vs.  Pregnancy. 

Menstruation  continues  ;  usually      Amenorrhoea  is  the  rule. 

increased. 
Cervix  not  softened.  Cervix  softened. 

Later. 

Absence  of  positive  signs  of  preg-      Positive  signs  present, 
nancy. 

How  would  you  differentiate  a  fibroid  tumor  from  an  ovarian 
cyst? 

Fibroid  Tumor  vs.  Ovarian  Cyst. 

Hard  and  firm.  Soft  and  elastic. 

More  intimately  connected  with      LesTTntimately  connected  with 

uterus.  uterus. 

More  central.  More  lateral. 

Menorrhagia  common.  Menstruation  normal  or  irregu- 

lar ;  Tnenorrhagia  rare. 

How  would  you  differentiate  a  fibroid  tumor  from  an  ectopic 
gestation  ? 

Fibroid  Tumor  vs.  Ectopic  Gestation. 

No  menstrual  period  skipped.  Menstrual     period    or    periods 

usually  skipped. 

Grows  less  rapidly.  *_  Grows  more  rapidly. 

More  central.  More  lateral. 

More  intimately  connected  with  Less  intimately  connected  with 

uterus.  uterus. 

No  decidual  membrane  cast  off.  Decidual  membrane  cast  off. 

Absence  of  attacks  of  very  severe  Such  attacks  occur. 

sharp  pain,  with  symptoms  of 

collapse. 


FIBROID   TUMORS   OF  THE   UTERUS.  1*1 

How  would  you  differentiate  a  fibroid  tumor  from  a  pelvic 
hematocele  ? 

Fibroid  Tumor  vs.            Pelvic  Hematocele. 

Gradual  development.  Rapid  development. 

Absence  of  acute  symptoms.  Symptoms  of  sudden  sharp  pain, 

shock  and  hemorrhage. 

Insensitive  to  pressure .  Sensitive  to  pressure. 

Hard  and  firm.  First  soft,  later  harder. 

Moves  with  uterus.  Does  not  move  with  uterus. 

How  would  you  differentiate  a  fibroid  tumor  from  a  pelvic 
inflammatory  deposit  ? 

Fibroid  Tumor  vs.         Inflammatory  Deposit. 

Slow  growth  ;  no  history  of  acute      History  of  rapid   development, 

inflammation.  and  acute  inflammation. 

Moves  with  uterus,  and  seems  a      Usually    does    not    move    with 
part  of  it.  uterus,  and  seems  less  a  part 

of  it. 
Insensitive  to  pressure.  Sensitive  to  pressure. 

What  is  the  prognosis  of  fibroid  tumors  ? 

It  will  depend  on  nearness  to  the  menopause,  rapidity  of  growth, 
pressure  symptoms,  and  endometritis ;  the  size  of  the  tumor  is  of 
comparatively  small  importance,  as  a  large  one  may  produce  few 
symptoms.  On  the  other  hand,  a  small  one,  no  bigger  than  a  pea, 
can  occasion  d3Tsmenorrhoea  or  hemorrhages. 

Death  results  from  anaemia,  sepsis,  urinary  disease  complicating 
pregnancy,  or  intestinal  obstruction. 

What  is  the  treatment  ? 

A  fibroid  if  small  may  give  rise  to  no  symptoms  and  need  no 
treatment. 

Treatment,  if  needed,  may  be  (1)  palliative  or  (2)  curative. 

Palliative  Treatment. — (a)  Drugs. — The  administration  of  ergot 
alone  or  in  combination  with  hydrastis  may  control  the  symptoms  until 
the  menopause  is  reached,  when  the  tumor  usually  diminishes  in 
size  ;  the  menopause,  however,  is  often  considerably  delayed. 

(b)  Curettage. — If   the    symptoms   are   chiefly   menorrhagia    or 


182  ESSENTIALS   OF  GYNAECOLOGY. 

metrorrhagia,  a  thorough  curettage  of  the  uterus,  followed  at  inter- 
vals by  astringent  applications  to  the  endometrium,  will  often  give 
marked  relief.  A  curettage,  however,  is  frequently,  if  not  usually, 
impossible.     In  some  cases  it  will  start  a  sloughing  of  the  growth. 

(c)  Diminution  of  Blood- supply. — Ligation  of  the  uterine  arteries 
from  the  vagina  has  been  employed,  but  has  now  given  place  to 
more  reliable  methods. 

Tait's  operation  of  removal  of  the  ovaries  and  tubes  has  in  many 
cases  been  not  only  palliative  but  curative,  but  its  present  interest 
is  only  historical. 

Curative  Treatment. — This  consists  of  either  myomectomy  or  hys- 
terectomy. 

Describe  the  operation  of  myomectomy. 

Myomectomy  consists  in  exposing  the  tumor  in  the  uterus,  either 
from  the  abdomen  or  vagina,  incising  the  capsule,  enucleating  the 
tumor,  and  closing  its  bed  with  catgut  sutures. 

This  operation  is  indicated  where  the  tumor  can  be  easily  removed 
without  serious  mutilation  of  the  uterus.  The  operation  is  gaining 
in  favor  and  may  be  employed  even  when  the  tumors  are  multiple. 

Hysterectomy  is  easier  and  less  shock  often  than  the  removal  of 
many  tumors  by  myomectomy ;  hence,  if  patient  is  near  the  meno- 
pause, if  children  are  not  desired  and  a  sound  ovary  can  be  left, 
hysterectomy  is  to  be  preferred  in  the  presence  of  many  tumors. 
What  are  the  varieties  of  hysterectomy  ? 

Hysterectomy,  removal  of  the  uterus,  may  be  performed : 

(a)  Through  the  vagina — vaginal  hysterectomy,  indicated  when 
the  uterus  and  tumor  are  small. 

(b)  Through  the  abdomen — abdominal  hysterectomy,  indicated 
when  the  uterus  and  tumor  are  large. 

Describe  the  operation  of  vaginal  hysterectomy  for  fibro- 
myoma  uteri. 

This  differs  from  the  operation  described  under  carcinoma  uteri 
only  in  the  fact  that  in  cases  where  fibro-myomata  are  large  enough 
to  cause  symptoms  the  uterus  with  its  tumors  is  often  too  large  to 
come  through  the  vagina  without  removing  it  piecemeal,  i.  e.  by 
morcellation.  After  thorough  disinfection  of  vulva  and  vagina,  the 
uterus  is  curetted  and  irrigated  with  a  sterile  solution ;  the  cervix 


FIBROID   TUMORS   OF  THE   UTERUS.  183 

is  drawn  down  and  separated  from  its  vaginal  attachments ;  the 
peritoneum  is  opened  anteriorly  and  posteriorly  and  the  uterine 
arteries  are  tied  on  both  sides.  If  the  uterus  is  too  large  to  be 
removed  as  a  whole,  wedge-  or  disc-shaped  pieces  are  removed  from 
its  centre  or  the  uterus  is  divided  in  the  median  line  and  each  half 
removed  separately,  care  being  taken  to  keep  up  traction  on  the 
uterus  by  volsellse  placed  above  the  part  to  be  removed.  The  broad 
ligaments  are  either  ligated  in  section,  or  if  more  convenient  during 
the  operation,  they  may  be  clamped,  and  after  the  uterus  is  removed 
these  clamps  may  or  may  not  be  replaced  by  ligatures  according  to 
the  judgment  of  the  operator.  After  the  removal  of  the  uterus, 
the  pedicles  are  inverted  into  the  vagina  and  sterile  or  iodoform 
gauze  placed  against  them. 

Describe  the  operation  of  abdominal  hysterectomy  for  fibro- 
myoma  uteri. 

The  preceding  operation,  owing  to  the  amount  of  technical  skill 
required  and  the  difficulty  in  safely  handling  intestinal  adhesions, 
has  largely  fallen  into  disrepute  and  given  place  to  one  of  the  two 
following  forms  of  abdominal  hysterectomy  : 

a.  In  one  the  cervix  is  removed — total  extirpation.  With  this 
are  associated  the  names  Eastman,  Martin,  Chorbak,  Polk. 

b.  In  the  other  the  cervix  is  left  in  the  abdominal  cavity — 
supravaginal  hysterectomy.     This  is  called  Baer's  method. 

In  both  of  these  methods,  after  opening  the  abdomen,  the  broad 
ligaments  are  tied  in  section  and  cut  close  to  the  uterus. 

In  the  total  extirpation  this  ligation  and  cutting  is  continued 
down  to  the  vagina :  this  is  freed  from  the  cervix  and  the  whole 
uterus  removed. 

In  the  supravaginal  hysterectomy  (Baer)  the  ligation  and  cut- 
ting of  the  broad  ligaments  is  continued  until  the  cervix  is  reached 
and  the  uterine  arteries  are  tied  and  cut ;  the  uterus  is  then  ampu- 
tated at  the  cervix,  and  the  latter  is  left,  the  vagina  not  being 
opened. 

In  each  of  these  methods  flaps  of  peritoneum  are  taken  from 
the  anterior  and  posterior  surfaces  of  the  uterus  before  its  removal, 
and  before  closing  the  abdomen  these  flaps  are  brought  together 
over  the  pedicles  in  the  bottom  of  the  pelvis. 


184  ESSENTIALS   OF   GYNAECOLOGY. 

Discuss  the  choice  of  operation. 

Myomectomy  has  been  performed  so  long  that  we  may  speak  with 
some  certainty  regarding  its  result.  It  has  been  followed  by  preg- 
nancy, and  the  scars  left  by  removal  of  fibroids  have  not  seemed  to 
interfere  with  the  enlargement  of  the  organ  or  its  postpartum  con- 
traction. It  is  not  contraindicated,  even  if  the  uterine  cavity  is  invaded, 
provided  the  removal  of  the  growth  does  not  sacrifice  a  complete 
segment  of  the  mucosa — a  continuous  strip  must  be  left  from 
fundus  to  cervix.  Recently  Russell  and,  following  him,  others  have, 
when  curettage  has  failed  to  check  menorrhagia  and  no  fibroid  could 
be  felt,  opened  the  abdomen,  split  the  fundus,  thus  exposing  the 
uterine  cavity,  and  removed  pea-sized  fibroids  from  the  uterine 
cornua,  and  closed  the  cut  in  the  uterine  wall.  Submucous  growths 
of  large  size  have  been  removed  much  after  the  manner  of  a 
Csesaran  section. 

Hysterectomy  is  easier  and  produces  less  shock  than  the  removal  of 
many  tumors  by  myomectomy,  and  has  hitherto  given  a  slightly  lower 
mortality  ;  hence,  if  the  patient  is  near  the  menopause,  and  if  children 
are  not  desired,  hysterectomy  is  to  be  preferred  in  the  presence  of 
many  tumors.  Vaginal  hysterectomy  is  the  operation  of  choice 
when  the  vagina  is  roomy  and  there  are  numerous  small  fibroids. 
When  the  fibroid  mass  is  large  it  may  still  be  removed  in  pieces 
(morcellation)  b\r  vagina,  though  this  course  is  not  recommended. 
If  the  operation  has  been  clone  without  immediate  accident,  the 
convalescence  is  usually  shorter  than  in  abdominal  hysterectomy. 

Abdominal  hysterectomy  is  the  operation  of  choice  in  the  difficult 
cases  and  in  most  patients  past  forty.  If  the  cervix  is  not  invaded 
by  the  growth  nor  otherwise  diseased,  we  prefer  to  leave  it,  as  the 
operation  is  surgically  cleaner  and  easier,  and  the  architecture  of  the 
vagina  is  not  altered.  In  some  cases  one  may  even  go  a  step 
further,  when  the  fibroids  are  well  up  toward  the  fundus,  and 
make  the  amputation  somewhat  higher  than  the  internal  os,  thus 
allowing  the  continuance  of  menstruation,  though  pregnancy  is 
impossible. 

Should  oophorectomy  accompany  hysterectomy  for  fibroids  ? 

It  is  wiser  to  leave  the  ovaries  unless  they  are  diseased.  If  there 
is  any  normal  ovarian  tissue  it  is  better  to  leave  one,  or  apart  of  one 
ovary,  than  to  remove  both,  and  thereby  bring  on  the  menopause. 


INVERSION   OF  THE  UTERUS.  185 

The  nervous  symptoms  of  the  artificial  menopause  are  likely  to  be 
more  exaggerated  the  earlier  in  life  it  occurs. 


Inversion  of  the  Uterus. 

What  is  the  pathology? 

In  inversion,  the  uterus  is  turned  more  or  less  completely  inside  out 

(see  Fig.  49). 

It  may  be  either — 

1.  Partial— where  the  depressed  uterine  wall  does  not   extend 

beyond  the  os  externum  ;  or 

Fig.  49. 


Inversion  of  Uterus  (half-size,  Barnes  from  Crosse's  essay).  The  fundus  lies  in  the 
vagina-  the  cervix  is  not  inverted;  the  lips  are  flattened  out  to  a  swelling  seen 
below  the  angle  of  inversion.  The  ovaries  (seen  from  behind)  are  not  in  the 
peritoneal  cup. 

2  Complete -where  the  inverted  body,  covered  with  mucous- 
membrane,  lies  outside  of  the  os  externum,  either  in  the  vagina  or 
between  the  labia. 

The    mechanism    of   production    of   the    inversion    is    as    lol- 

A  portion  of  the  uterine  wall  loses  its  tone,  is  depressed  into  the 
uterine  cavity,  usually  by  traction  from  below  or  abdominal  pressure 
from  above;  the  depressed  portion  is  then  grasped  by  the  unde- 
pressed portion  and  forced  toward  or  through  the  cervix. 


186  ESSENTIALS  OF  GYNECOLOGY. 

The  peritoneum  follows  the  depression  of  the  uterine  wall,  and 
lines  the  cup  thus  formed.  The  appendages  may  or  may  not  lie 
within  the  cup. 

The  inversion  occurring  during  the  puerperium  usually  begins  at 
the  placental  site  ;  when  produced  by  intra-uterine  tumors,  it  usually 
begins  at  the  attachment  of  the  tumor.  The  uterine  mucous  mem- 
brane is  usually  congested  ;  it  may  ulcerate  ;  sometimes  it  becomes 
gangrenous.  Occasionally  it  becomes  covered  with  squamous  epi- 
thelium, and  resembles  skin. 

What  is  the  etiology  ? 

Inversion  is  predisposed  to  by — 

(a.)  Parturition. 

(b. )  Distention  of  the  uterus  from  any  cause. 

(  c. )  Intra-uterine  tumors. 

(d. )  Degeneration  of  uterine  walls. 
According  to  the  time  and  cause  of  production,  two  varieties  are 
recognized  : — 

1.  Puerperal. — Produced  during  the  puerperium,  either  by  ab- 
dominal pressure  or  mismanagement  in  the  delivery  of  the  placenta, 
especially  the  latter,  traction  on  the  cord  being  one  of  the  most  fre- 
quent causes. 

2.  Non-puerperal. — Secondary  to  intra-uterine  tumors ;  especially 
pedunculated  fibroids  growing  from  the  fundus. 

The  puerperal  variety  is  much  more  common  than  the  non-puer- 
peral. The  former  is  usually  rapid  in  development ;  the  latter 
gradual. 

When  the  inversion  is  developed  and  reduced  during  the  puer- 
perium, it  is  called  acute  ;  otherwise,  chronic  inversion. 

What  are  the  symptoms  ? 

At  the  time  of  the  occurrence  of  acute  inversion,  there  is  pain, 
hemorrhage,  shock,  a  feeling  as  of  something  giving  way,  and  of  full- 
ness in  the  vagina. 

This  belongs  especially  to  obstetrics. 

The  symptoms  of  the  chronic  inversion  are  hemorrhage,  dragging 
pain  in  the  pelvis,  discomfort  from  the  foreign  body  in  the  vagina, 
leucorrhoea,  anaemia  and  general  malaise.  Rarely  inversion  exists 
with  very  few  symptoms. 


INVERSION  OF  THE  UTERUS. 


187 


What  are  the  physical  signs  ? 

These  depend  on  whether  the  inversion  is  partial  or  complete,  acute 
or  chronic.  In  the  partial  variety  the  cupping  may  be  felt  by  the 
hand  on  the  abdomen,  and  the  inverted  portion  detected  by  the  use 
of  the  sound  in  the  uterus.  In  the  acute,  complete  inversion,  one 
feels  a  soft,  bulging  tumor  in  the  vagina  or  between  the  labia  ;  it 
bleeds  easily,  is  sensitive  and  smaller  above  where  it  is  encircled  by 

Fig.  51. 


Fig.  50. 


Inversion  of  Uterus  (after 
Thomas).  A  cup-shaped 
depression  is  in  the  place 
of  the  uterus.  Sound  ar- 
rested at  angle  of  flexion. 


Uterine  Polypus  (after 
Thomas).  The  uterus 
in  its  normal  position. 
Sound  passes  into 
uterine  cavity. 


the  cervix ;  it  may  or  may  not  have  the  placenta  attached  to  it.  The 
sound  passes  around  the  tumor,  but  only  a  short  distance  into  the 
cervix.  The  hand  on  the  abdomen  detects  the  absence  of  the  fundus 
and  the  presence  of  the  cervical  ring.  The  physical  signs  of  the 
chronic  inversion  are  similar,  save  that  the  mass  in  the  vagina  is 
smaller,  harder,  and  in  the  non-puerperal  variety  perhaps  has 
attached  to  it  the  tumor  which  was  its  cause. 


From  what  must  you  differentiate  inversion  of  the  uterus  ? 
From  polypi  and  prolapsus  uteri. 


188 


ESSENTIALS   OF  GYNECOLOGY. 


How  would  you  differentiate  inversion  of  the  uterus  from  a 
polypus  ? 

The  diagnosis  of  a  complete  inversion  (see  Fig.  50)  from  a  polypus 
lying  in  the  vagina  (see  Fig.  51)  would  be  made  as  follows : — 


Inversion 
Fundus  not  felt  in  the  abdomen ; 

cervical  ring  felt. 
Sound  passes  all  around  tumor, 

but  only  a  short  distance  into 

the  cervix. 


vs.  Polypus. 

Fundus  felt  in  the  abdomen. 

Sound  passes  into  the  uterus,  at 
the  side  of  the  tumor,  more 
than  2J  inches. 


The  differential  diagnosis  between  a  partial  inversion  and  an  intra- 
uterine polypus  (see  Figs.  52  and  53)  is  often  quite  difficult.  Careful 
examination  by  the  ordinary  bimanual  and  by  the  abdomino-rectal 
method  may  detect  the  cup-shaped  depression  of  the  partial  inver- 


Fig.  53. 


Fig.  52. 


Partial  Inversion  of  Uterus 
(after  Thomas). 


Polypus  still  Intra-uterine 
(after  Thomas). 


sion.     Enlargement  of  the  uterus  rather  favors  the  diagnosis  of 
polypus. 
Both  of  these  conditions  may  rarely  coexist. 

How  would  you  differentiate  inversion  of  the  uterus  from 
complete  prolapse  ? 

This  rarely  causes  difficulty.     It  is  made  by  finding  in  the  latter 


INVERSION  OF  THE  UTERI'S. 


189 


the  external  os,  the  obliteration  of  the  fornices,  and  by  passing  the 
sound  into  the  uterine  canal. 

What  are  the  results  of  an  untreated  inversion? 

Very  rarely  it  reduces  itself.  Rarely  the  patient  suffers  little 
inconvenience  from  it. 

Usually  the  patient  dies  from  hemorrhage  or  sepsis. 

What  is  the  treatment  ? 

The  object  sought  is  the  reposition  of  the  fundus  uteri. 

Emmet's  method  (see  Fig.  54)  consists  in  inserting  the  right  hand 
into  the  vagina,  grasping  the  fundus  in  the  palm,  inserting  the 
fingers  into  the  cervix  and  pushing  upward  ;  at  the  same  time  sepa- 
rating the  fingers  as  much  as  possible.  The  left  hand  meanwhile 
exercises  through  the  abdomen  counter-pressure  on  the  cervical  ring. 

Noeggerath  begins  the  reposition  by  dimpling  in  one  horn  of  the 
uterus,  and  then  uses  this  as  a  wedge  to  dilate  the  cervix. 

Fig.  54. 


Reposition  of  the  Inverted  Uterus  with  the  Hand  alone  (after  Emmet). 

Instead  of  the  hand  alone,  cup-shaped  repositors  are  often  made 
use  of. 

In  all  these  methods  the  patient  is  usually  best  prepared  for  the 
manipulation  by  the  administration  of  prolonged  hot-water  douches, 


190 


ESSENTIALS  OF  GYNAECOLOGY. 


and  the  introduction  of  a  vaginal  elastic  bag,  to  be  distended  with 
air  or  water,  and  worn  twelve  to  twenty-four  hours. 

The  manipulations  are  best  performed  under  anaesthesia. 

When  the  above  methods  fail,  hysterectomy  probably  offers  the 
best  result. 


Fig.  55. 


Polypi. 

What  is  meant  by  the  term  " uterine  polypus,"  and  what 
are  the  varieties? 
A  polypus  is  a  pedunculated  tumor  attached  to  the  uterine  mucous 
membrane.     The  following  varieties  are  recognized : — 

1.  Fibrous  polypi. 

2.  Mucous  polypi. 

3.  Pedunculated      Na- 
bothian  follicles. 

4.  Placental  polypi. 

5.  Papillomata  of   the 
cervix. 

Describe     briefly    the 
fibrous  polypi. 

Fibrous  polypi  are  sub- 
mucous fibroids  which 
have  become  peduncu- 
lated ;  at  first  lying  within 
the  uterus  ;  later,  dilating 
the  cervix  and  becoming 
vaginal  (see  Fig.  55),  some- 
times even  projecting  be- 
yond the  vulva. 

They  spring  from  the 
muscular  wail  of  the  ute- 
rus, more  often  from  the 
body  than  cervix ;  they 
are  composed  chiefly  of 
fibrous  tissue  with  few 
blood  vessels.  Their  pres- 
ence sets  up  uterine  contractions,  which  gradually  expel  them. 
Their  shape  is  usually  pyriform  or  ovoid. 


Intra-uterine  Submucous  Fibroid  which  is 
becoming  Vaginal  {Sir  J.  Y.  Simpson). 


POLYPI. 


J'J] 


Describe  the  mucous  polypi. 

These  spring  from  the  uterine  mucous  membrane,  chiefly  that  of 
the  cervix.  There  are  usually  more  than  one  (see  Fig.  56) ;  they  are 
small,  soft,  vascular,  and  on  section  present  the  structure  of  mucous 
membrane. 

What  are  the  pedunculated  Nabothian  follicles  ? 

They  are  the  glands  of  the  cervical  mucous  membrane  which  have 
become  obstructed,  formed  retention  cysts  and  assumed  the  polypoid 
shape. 

What  are  placental  polypi  ? 

They  are  portions  of  undetached  placenta  which  have  received  nutri- 

Fig.  56. 


Group  of  Mucous  Polypi  growing  in  the  Cervix  Uteri  (Sir  J.  Y.  Simpson). 

ment  from  their  attachment  to  the  uterus,  have  become  coated  with 
fibrin  and  so  increased  in  size.  By  the  uterine  contractions  they  are 
made  more  pedunculated,  and  may  be  extruded  from  the  cervix. 

Describe  the  papillomatous  variety  of  polypus. 

Papilloma  of  the  cervix  is  almost  always  either  a  malignant  new 


192 


ESSENTIALS   OF  GYNECOLOGY. 


growth  or  tends  soon  to  become  so.  It  is  often  called  a  "cauli- 
flower excrescence"  (Clarke)  (see  Fig.  57),  is  usually  soft,  friable, 
and  bleeds  easily. 

What  are  the  symptoms  of  polypi  ? 

1.  Hemorrhage. — First  menorrhagia,  then  metrorrhagia,  the 
source  of  the  blood  being  the  mucous  membrane,  which  covers,  or 
in  the  mucous  variety  forms,  the  substance  of  the  polypus. 

2.  Leucorrhoea. — Due  to  the  accompanying  endometritis. 

3.  Pain. — Due  to  the  efforts  of  the  uterus  to  expel  the  tumor. 

4.  Sterility. — Due  to  the  mechanical  obstruction  and  to  the  endo- 

metritis. 
Fig.  57.  5.  Anaemia  and  general  malaise. — 

Resulting  from    the    foregoing  condi- 
tions. 

What  are  the  physical  signs  ? 

When  the  polypus  has  passed  the  os 
externum,  the  finger  in  the  vagina  de- 
tects a  pyriform  or  ovoid  body,  hard  or 
soft  according  to  the  variety;  it  is 
movable  and  seems  to  come  from  the 
os.  The  use  of  the  speculum  deter- 
mines its  appearance. 

If  it  is  a  fibrous  polypus,  the  bi- 
manual examination  usually  shows  the 
uterus  enlarged,  and  the  sound  proves 
the  cavity  elongated. 

When  the  polypus  is  intra-uterine, 
the  sound  in  some  cases  will  detect  its 
presence ;  in  other  cases  dilatation  of 
the  cervix  and  introduction  of  the  fin- 
ger is  necessary. 

What  is  the  treatment  ? 

When  the  polypus  is  of  considerable 

size  and  lies  within  or  external  to  the 

os,  the  best  treatment  is  removal  by  the  wire  ecraseur,  putting  the 

wire  loop  as  near  the  uterine  attachment  of  the  pedicle  as  possible. 

Small  polypoid  projections  may  be  scraped  away  with  the  curette ; 

cervical  polypi  may  usually  be  twisted  off  with  the  forceps. 


Cauliflower  Excrescence  growing 
from  the  Cervix  Uteri  (Sir  J. 
Y.  Simpson). 


CARCINOMA  UTERI.  193 

When  the  polypus  lies  within  the  uterus,  dilate  the  cervix  and 
apply  the  ecraseur. 

If  the  pedicle  is  small,  blunt,  dull  scissors  may  be  substituted  for 
the  ecraseur.  If  the  pedicle  is  large  or  dilatation  of  the  cervix  is 
necessary,  anaesthesia  is  to  be  employed. 

All  antiseptic  precautions  are  to  be  used. 


Carcinoma  Uteri. 

What  is  the  pathology  ? 

Carcinoma  may  begin  in  the  cervix  or  body,  being  five  times  more 
frequent  in  the  former.  That  of  the  cervix  is  of  several  forms.  It 
may  begin  in  the  squamous  cells  of  the  vaginal  surface  ;  this  is  the 
epithelioma  or  cauliflower  excrescence  of  the  cervix.  Microscopically 
it  consists  of  plugs  of  epithelial  cells  extending  deeply  into  the 
cervical  tissue.  Epithelial  pearls,  common  in  epithelioma  of  the 
skin,  are  rarely  seen  here.  This  variety  spreads  early  to  involve 
the  vaginal  wall. 

Carcinoma  of  the  cervical  canal  originates  from  the  epithelium 
lining  the  canal  or  from  that  of  the  glands.  These  growths  break 
down,  forming  necrotic  ulcers  with  indurated  edges.  The  vagina 
and  body  may  become  involved  by  direct  extension  and,  through 
the  agency  of  the  lymphatics,  the  musculature  and  broad  ligaments 
are  involved.     Involvement  of  lymph-nodes  is  a  late  occurrence. 

Carcinoma  of  the  uterine  body  arises  from  the  lining  epithelium 
of  the  cavity  or  from  its  tubular  glands,  and  presents  the  appearances 
common  to  adeno-carcinomata.  The  occurrence  of  primary  squa- 
mous-celled  carcinoma  of  the  body  of  the  uterus  is  admitted  by 
Amann  and  others.  Carcinoma  of  the  body  is  diffuse,  circumscribed, 
or  polypoid. 

What  is  the  etiology  ? 

The  etiology  of  cancer  of  the  uterus  is  still  unsettled.  The  factors 
which  favor  its  development  are  age,  heredity,  parturition,  laceration 
of  the  cervix,  with  erosion  and  depreciation  of  the  vital  powers. 

1.  Age. — It  occurs  at  any  age  from  20-80,  but  is  most  common 
at  middle  life.     It  is  because  of  its  frequency  at  this  time  that 
women  have  come  to  think  of  the  menopause  as  an  especially  dan- 
gerous period  of  life. 
13 


194 


ESSENTIALS   OF   GYNAECOLOGY. 


2.  Heredity. — Although  regarded  as  of  less  importance  than  for- 
merly, its  influence  seems  to  be  exemplified  in  some  cases. 

3.  Parturition. — Frequent  child-bearing  apparently  creates  a 
marked  predisposition  to  carcinoma  of  the  cervix.  When  a  mucip- 
arous woman  gets  carcinoma  it  is  usually  of  the  body  of  the  uterus. 

4.  Laceration  of  the  Cervix. — Cancer  of  the  cervix  seems  often  to 
arise  from  a  laceration,  with  erosion  and  cervical  endometritis. 

Fig.  58. 
70-79  yrs...  4  2  cases 

60-69  YP5..  /|lk36CAS£5 


117  CASE5 


*W9WI5. 


ZMCAJEJ 


158  CASES 


20-29  YRS 
VP  TO  ZQYRJ.NO  CASES.* 


Analysis  of  631  cases,  indicating  the  ages  at  which  carcinoma  most  frequently 
occurs  (adapted  by  Clark  from  Kroemer's  statistics). 

5.  Depreciation  of  the  Vital  Powers. — Poor  surroundings,  poor 
food  and  air,  and  hardships  of  any  kind  seem  to  predispose  to  cancer. 

What  are  the  symptoms  ? 

1.  Hemorrhage. — This  is  usually  the  first  symptom.  If  hemor- 
rhage occurs  after  the  menopause,  always  suspect  cancer.  Even  at 
its  beginning  it  is  a  metrotaxis  having  no  relation  to  menstruation. 
The  first  hemorrhage  may  follow  trauma,  such  as  coitus  or  sudden 
exertion,  and  appears  earlier  in  the  cauliflower  variety. 

2.  Offensive  Discharge. — Does  not  occur  until  ulceration  begins. 


CARCINOMA  UTERI.  195 

The  odor  is  due  to  putrefaction  of  the  broken-down  tissues.  The 
discharge  is  totally  unlike  ordinary  leucorrhoea.  It  is  serous  in 
character — i  e. .  an  exudate — and  is  often  described  as  ' '  watery  ' '  or 
"  dish-watery,"  because  its  fluid  is  mingled  with  broken-down  par- 
ticles of  tumor. 

3.  Pain. — When  the  cervix  is  alone  involved,  pain  is  usually 
absent.  When  the  disease  has  extended  to  the  cellular  tissue  or 
peritoneum,  or  involves  the  body  of  the  uterus,  pain  is  common. 

4.  Cachexia. — This  is  always  present  to  a  greater  or  less  extent 
in  the  later  stages. 

5.  Septic  infection  is  not  infrequent  and  gives  rise  to  pyometra, 
salpingitis,  or  pyosalpinx. 

What  other  conditions  may  cause  bleeding  after  the  meno- 
pause ? 
Though  carcinoma  is  the  usual  cause,  it  may  be  due  to  senile 
vaginitis  or  sarcoma,  more  rarely  to  a  mucous  polypus  or  sloughing 
fibroid. 

What  are  the  physical  signs? 

If  the  disease  affects  the  vaginal  portion  of  the  cervix,  the  examin- 
ing finger  detects  a  roughs  ulcerated,  and  indurated  area,  or  perhaps 
a  fungoid  mass.  On  withdrawal,  the  finger  is  usually  stained  with 
blood  and  emits  a  foul  odor.  The  speculum  gives  us  the  appearance 
of  the  growth. 

When  the  cervical  canal  is  the  point  of  origin  one  may  feel  a 
nodular  cervix  larger  than  normal  and  of  almost  stony  hardness,  or, 
more  commonly,  the  examining  finger  enters  a  crater-like  cavity  in 
the  cervix,  with  indurated  walls  that  readily  break  clown  and  bleed 
during  examination.  The  nodular  type  of  growth  is  characterized 
by  induration,  the  excavated  type  by  ulceration. 

Carcinoma  of  the  body  of  the  uterus  enlarges  it  and  may  be  de- 
tected by  the  sound.  In  some  cases  the  growth  early  infiltrates  the 
muscular  wall  of  the  uterus,  in  others  remains  for  a  considerable 
time  as  a  polypoid  growth,  and  hence  offers  a  better  prognosis. 

When  the  disease  has  extended  beyond  the  limits  of  the  uterus, 
the  broad  ligaments  and  base  of  the  bladder  will  give  the  impression 
of  stony  hardness  to  the  examining  finger,  and  the  normal  mobility 
of  the  uterus  is  much  restricted. 

At  times  the  lymph -nodes  are  enlarged  and  the  broad  ligaments 


196  ESSENTIALS   OF  GYNECOLOGY. 

thickened  by  complicating  inflammation,  and  this  gives  us  the  im- 
pression that  the  growth  is  more  extensive  than  is  really  the  case. 

What  is  the  prognosis? 

It  is  better  in  cancer  of  the  corpus  uteri  than  of  the  cervix,  but 
is  bad  in  both.  Many  have  passed  the  operable  stage  when  first 
applying  for  treatment.  The  percentage  of  operability  has  been 
variously  stated,  some  put  it  as  low  as  11,  some  as  high  as  50  per 
cent,  of  the  cases  diagnosed  as  carcinoma.  It  can  be  improved 
by  earlier  diagnosis  made  by  microscopical  examination  of  curettings 
in  all  suspected  cases.  So  much  depends  on  early  diagnosis  that  in 
Germany  the  education  of  the  lay  public  has  been  attempted  in  re- 
gard to  the  early  symptoms  of  cancer  and  the  necessity  of  an  exam- 
ination when  suspicious  symptoms  are  present. 

Are  iliac  nodes  involved  early  in  cancer  of  the  cervix  ? 

On  this  subject  opinions  are  at  variance.  Some  nodes  that  are 
enlarged,  on  section  prove  to  be  only  hyperplastic.  Almost  all 
writers  think  the  metastasis  in  lymph-nodes  is  later  in  cancer  of  the 
uterus  than  of  the  breast. 

What  is  the  treatment  of  carcinoma  of  the  uterus  ? 

1.  Radical. — 

When  the  disease  is  limited  to  the  uterus,  either  cervix  or  body, 
hysterectomy  is  indicated.  Aside  from  the  appearance  of  the  dis- 
eased area  viewed  through  a  speculum,  the  mobility  of  the  uterus 
largely  determines  whether  or  not  the  disease  has  extended  beyond 
it.  If  the  uterus  is  fixed  in  the  pelvis,  hysterectomy  is  usually 
contraindicated. 

The  combined  abdominal  and  vaginal  method  offers  some  advan- 
tages. Werder  ligates  both  broad  ligaments  through  the  abdomen, 
and  continues  his  dissection  downward  till  the  upper  part  of  the 
vagina  is  separated  from  its  attachments. 

The  patient  is  then, put  into  the  lithotomy  position,  a  circular 
incision  is  made  through  the  vaginal  wall  some  distance  below  the 
cervix,  and  the  mass,  consisting  of  uterus,  appendages,  and  part  of 
the  vagina,  is  removed  through  the  vagina. 

Some  operators  advocate  a  very  extensive  operation  through  the 
abdomen,  removing  the  broad  ligaments  clear  out  to  the  pelvic  wall, 
Hgating  the  uterine  artery  at   its  origin ;  removing  the  iliac  nodes 


CARCINOMA  UTERI.  197 

and  dissecting  out  the  ureter,  and  removing  a  portion  of  it  if  it  is 
involved  in  the  cancerous  mass.  Such  a  procedure  is  still  subjudice, 
since  the  operative  mortality  from  shock  and  ureteral  sloughing  and 
infection  is  much  increased  while  the  question  of  permanent  recovery 
is  yet  undecided. 

2.  Palliative. — When  a  radical  operation  is  contraindicated,  the 
following  methods  of  treatment  are  of  value  : — 

If  hemorrhage  is  a  marked  symptom,  and  sloughing  masses  are 
present  at  the  seat  of  ulceration,  thoroughly  curette  the  surface  and 
apply  carbolic  acid,  iodized  phenol,  a  solution  of  chloride  of  zinc,  or 
the  actual  cautery.  Frequent  insertions  of  iodoform  gauze  soaked 
in  a  4  per  cent,  solution  of  chloral  will  be  found  to  act  as  an  anti- 
septic and  anaesthetic  to  the  ulcerated  surface. 

For  the  foul  discharges,  vaginal  douches  of  a  weak  solution  of  creo- 
lin,  peroxide  of  hydrogen,  or  permanganate  of  potash  are  of  value. 
Pure  acetone,  applied  directly  to  the  sloughing  area  through  a  tubu- 
lar speculum,  is  highly  recommended  for  controlling  the  putrefaction. 

The  pain  and  distress  in  the  later  stages  demand  opium. 

Attention  to  the  general  health  is  of  course  indicated. 

Describe  briefly  the  operation  of  vaginal  hysterectomy. 

Different  operators  differ  somewhat  in  the  details  of  the  operation. 
The  main  features  of  the  operation  are  as  follows:  The  vulva  is 
shaved,  and  the  vagina  and  vulva  thoroughly  disinfected.  The 
uterus  is  drawn  down  and  held  by  an  assistant;  a  semicircular 
incision  is  made  around  the  cervix  in  the  anterior  fornix,  and  the 
cervix  is  separated  from  the  bladder  up  to  the  utero-vesical 
pouch  of  the  peritoneum.  The  cervix  is  drawn  forward  and  the 
posterior  fornix  opened  by  a  semicircular  incision  about  the  cervix, 
which  is  then  freed  up  to  the  pouch  of  Douglas.  The  pouch  of 
Douglas  may  now  be  opened,  and  a  clean  sponge  with  a  long  piece  of 
silk  attached,  introduced  to  keep  back  the  intestines.  The  uterus  is 
freed  from  the  lower  portion  of  the  broad  ligaments  by  ligaturing 
in  section,  and  then  cutting  with  scissors  close  to  the  uterus.  The 
latter  may  now  be  retroverted  through  the  opening  in  the  pouch  of 
Douglas,  and  freed  from  the  upper  portion  of  the  broad  ligaments 
by  ligaturing,  and  cutting  close  to  the  uterus.  It  is  well  to  draw 
the  ovaries  into  the  ligature,  so  that  they  will  be  removed  with  the 


198  ESSENTIALS   OP  GYNECOLOGY. 

uterus.  The  anterior  reflection  of  peritoneum  may  now  be  divided, 
or,  as  practiced  by  many  operators,  this  may  be  done  before  retro- 
verting  the  uterus.  All  hemorrhage  is  checked  and  the  parts  are 
cleaned  ;  the  peritoneum  is  stitched  to  the  vaginal  wall ;  and  a  single 
suture  unites  the  anterior  and  posterior  vaginal  walls  in  the  median 
line.  Two  small  strips  of  iodoform  gauze  are  placed  in  contact  with 
the  stumps  of  the  broad  ligaments  and  their  ends  brought  out 
through  the  vagina. 

Some  use  clamps  throughout  the  operation  instead  of  ligatures. 

What  are  the  relative  merits  of  abdominal  and  vaginal  hys- 
terectomy in  carcinoma  ? 

The  vaginal  operation  is  usually  the  easier,  and  can  at  times  be 
done  in  a  short  time  with  scarcely  any  shock  or  blood  loss.  When 
one  recalls  the  age  of  the  patients,  the  anaemia  and  poor  physique 
of  many  of  them  at  the  time  of  operation,  the  importance  of  these 
considerations  is  apparent.  With  the  narrow,  contracted  vagina  of 
the  nulliparous  the  operation  may  be  very  difficult.  Vaginal  hys- 
terectomy, however,  can  remove  little  beside  the  uterus  and  the 
adjacent  portion  of  the  vaginal  wall.  Since  this  is  a  much  less  radi- 
cal operation  than  that  performed  upon  the  breast,  and,  since  early 
local  recurrence  is  the  rule,  attention  was  turned  to  the  abdominal 
route  as  offering  the  only  chance  of  a  more  thorough  operation. 
Reiss,  Wertheim,  and  Clark  have  advocated  the  abdominal  removal 
of  uterus,  broad  ligaments,  upper  vagina,  and  glands.  This  opera- 
tion is  much  more  difficult  than  hysterectomy  for  fibroid  or  pyosal- 
pinx.  It  is  a  two-hour  operation  in  most  hands,  and  without  con- 
siderable experience  will  have  a  much  higher  primary  mortality  than 
the  vaginal  operation.  Clark  has  receded  from  his  former  position 
in  that  he  no  longer  recommends  routine  removal  of  glands.  Wer- 
der,  whose  former  operation  was  extensive,  has  now  gone  to  the 
opposite  extreme  of  using  the  galvano-cautery  methods  of  Byrne. 
He  claims  that  the  permanent  results  are  equally  good,  and  there  is 
no  primary  mortality.  It  may  be  too  soon  to  speak  definitely  on  the 
choice  of  operation,  but  we  think  the  ease  of  operation  in  an  indi- 
vidual case  will  have  a  bearing.  We  shall  have  to  take  into  consid- 
eration such  matters  as  the  thickness  of  the  abdominall  wall,  the 
roominess  of  the  vagina,  the  extent  and  direction  of  growth,  and 
the  operator's  facility  with  the  two  operative  routes. 


SARCOMA   OF  THE  UTERUS.  199 

Sarcoma  of  the  Uterus. 

What  is  the  pathology  ? 

Sarcoma  of  the  uterus  is  a  growth  usually  originating  in  the  con- 
nective tissue  of  the  mucosa  and  early  appearing  as  a  diffuse  infiltra- 
tion of  it,  and  later  extending  to  the  uterine  muscle.  It  may,  how- 
ever, begin  as  a  nodule  in  the  muscular  wall.  It  usually  affects  the 
body  of  the  uterus,  being  rare  in  the  cervix.  The  masses  are  usually 
grayish  in  color,  soft  and  brain-like  ;  occasionally  the  circumscribed 
masses  are  firm  and  resemble  fibroids,  but  have  no  capsule.  They 
usually  do  not  ulcerate  as  rapidly  or  deeply  as  carcinoma,  but  form 
larger  tumors,  and  metastases  are  less  common. 

What  is  the  etiology  ? 

Little  is  known  concerning  it.  It  is  most  frequent  between  the 
ages  forty  to  fifty,  but,  unlike  carcinoma,  often  occurs  in  nulliparous 
women. 

What  are  the  symptoms  ? 

1.  Hemorrhage. 

2.  Watery  discharge. 

3.  Pain. 

4.  Cachexia. 

Thus  the  symptoms  are  similar  to  those  of  carcinoma.  Some 
authors  claim,  however,  that  the  discharge  is  less  offensive  than  in 
carcinoma,  because  there  is  less  tissue  necrosis.  It  is  much  less 
common  than  carcinoma  uteri. 

What  are  the  physical  signs  ? 

The  uterus  is  usually  enlarged;  the  sound,  when  introduced, 
detects  great  irregularity  of  the  endometrium,  and  usually  causes 
bleeding.  If  the  curette  is  used,  a  grayish,  brain-like  material  is 
removed. 

With  what  are  sarcoma  and  carcinoma  of  the  body  of  the 
uterus  most  likely  to  be  confused,  and  how  is  the 
diagnosis  made  ? 

They  are  chiefly  to  be  confused  with  villous  endometritis,  sloughing 
polypi  or  retained  secundines.  The  diagnosis  is  made  by  removing 
fragments  with  the  curette,  knife  or  scissors,  and  subjecting  them  to 


200  ESSENTIALS   OF  GYNAECOLOGY. 

microscopical  examination.  Marked  anaemia  and  emaciation  would 
lead  one  to  suspect  malignant  disease,  yet  severe  endometritis  or  a 
vascular  polypus  may  cause  similar  symptoms. 

What  is  the  treatment  ? 

Hysterectomy  gives  us  the  only  prospect  of  cure. 

The  palliative  treatment  consists  in  curetting  and  applying  caustics 
to  the  interior  of  the  uterus,  keeping  the  vagina  clean  with  anti- 
septic douches,  as  weak  creolin,  and  relieving  pain  with  opium. 

Chorio-Epithelioma. 

What  are  its  synonyms  ? 

Syncytioma,  decidual  celled  sarcoma,  syncytial  carcinoma,  and 
deciduoma  malignum.  These  terms  have  been  applied  to  a  fairly 
well-defined  group  of  cases  of  malignant  uterine  disease,  whose 
pathological  appearances  have  varied  somewhat  in  different  cases. 

Give  its  pathology. 

The  tumors  consist  of  masses  of  cells  often  surrounding  spaces 
filled  with  blood  and  fibrin.  The  cells  are  round,  spindle,  or  polyg- 
onal, depending  on  how  close  they  are  packed  together.  Further- 
more they  contain  irregular  masses  or  streaks  of  protoplasm  with 
nuclei  scattered  through  them,  but  with  no  division  of  the  proto- 
plasm into  cells. 

When  first  described  by  Sanger  the  tumor  was  called  a  deciduoma, 
since  he  thought  its  cells  closely  simulated  the  maternal  decidual 
cells.  It  is  now  pretty  thorough^  established  that  these  tumors  are 
of  foetal  trophoblastic  origin.  In  some  cases  both  syncytium  and 
Langhans'  cells  are  recognizable.  Indeed,  even  fairly  well  con- 
structed villi  are  seen.  It  is  known  that  villi  may  be  transported 
through  the  maternal  veins  as  emboli  in  normal  pregnancy,  but 
these  do  not  proliferate,  but  are  absorbed  by  other  body  cells. 
Chorio-epithelioma  is  one  of  the  most  remarkable  of  tumors,  since 
it  is  a  tumor  of  one  individual — the  foetus  growing  in  the  tissues  of 
another  individual — the  mother.  Though  of  epithelial  origin,  it 
forms  metatases  through  veins  rather  than  lymphatics.  Ewing 
thinks  the  term,  as  at  present  used,  includes  several  varieties  of 
growths:  1.  Syncytioma,  almost  entirely  composed  of  syncytium 
and  of   fairly  good  prognosis.     2.  Chorio-adenoma,  in  which  re- 


SALPINGITIS.  201 

covery  may  occur,  and  which  exhibits  a  villous  structure.    3.  Chorio- 
carcinoma, which  has  always  proved  fatal. 

Give  its  course  and  symptoms. 

It  occurs  most  often  between  the  age  of  twenty  and  thirty-five 
years.  It  always  follows  a  pregnancy,  and  in  nearly  half  the  cases 
has  followed  hydatidiform  mole.  Hemorrhage,  watery  discharge, 
and  pain  rapidly  appear.  Metastases  are  early  and  numerous. 
The  vagina  and  vulva  are  often  involved  by  extension  or  metastasis, 
and  before  death  a  number  of  abdominal  and  thoracic  organs  will 
show  tumors  whose  microscopic  appearances  closely  imitate  those 
of  the  uterine  growth.  Unlike  tumors  in  general  of  epithelial 
origin,  its  metastases  occur  chiefly  through  the  veins,  hence  the 
lungs  are  usually  infected  early.  Death  will  follow,  as  a  rule,  within 
six  months  of  the  termination  of  the  preceding  pregnancy. 

What  is  the  treatment? 

The  symptoms  given  describe  the  most  malignant  type.  In  some 
cases  curettings  have  shown  a  condition  of  chorio-epithelioma,  yet 
death  has  not  followed,  whether  the  uterus  was  or  was  not  removed. 
Hence  we  are  led  to  infer  that  we  are  dealing  with  different  classes 
of  tumors,  as  Ewing  maintains.  If  the  pathologists  are  able  to 
distinguish  the  classes  by  examination  of  curettings.  we  may  be  able 
to  modify  our  treatment  in  the  direction  of  conservatism.  At 
present  early  hysterectomy  would  seem  the  only  safe  procedure. 

Salpingitis. 

What  is  the  pathology  ? 

In  salpingitis  there  is  usually  first  a  catarrhal  or  suppurative 
inflammation  of  the  mucous  membrane  of  the  tube  ;  this,  extending 
to  the  peritoneum,  sets  up  a  localized  peritonitis  which  usually  closes 
the  fimbriated  extremity,  and  often  by  adhesions  distorts  the  tube. 
From  the  closure  of  the  outer  extremity  and  the  narrowing  of  the 
lumen  in  different  places  by  the  traction  of  peritonitic  adhesions, 
the  secretions  are  retained  and  distend  the  tube.  This  distention 
is  favored  by  the  softening  arising  from  the  inflammation.  Other 
portions  of  the  tube  may  be  thickened,  partly  from  inflammation 
of  the  tube  itself  and  partly  from  the  neighboring  peritonitis. 

We  distinguish,  according  to  their  severity,  the  following  forms  of 
salpingitis : 


202  ESSENTIALS  OF  GYNAECOLOGY. 

1.  Catarrhal,  due  to  germs  of  impaired  virulence  or  to  extension 
of  nearby  inflammatory  processes. 

2.  Suppurative: 

a.  Endo-salpingitis,  chiefly  gonorrhoea! 

b.  Parietal  salpingitis,    chiefly  secondary  to   broad    ligament 

inflammations. 

3.  Chronic.  The  tortuous,  clubbed,  or  adherent  tubes  resulting 
from  previous  acute  processes. 

How  do  the  tube  ends  become  occluded  ? 

The  lumen  at  the  uterine  end  is  closed  by  swelling  of  mucosa,  but 
is  not,  as  a  rule,  completely  obliterated.  The  term  "salpingitis 
profluens,"  or  intermittent  salpingitis,  is  applied  to  cases  where, 
owing  to  re-establishment  of  the  lumen,  fluid  is  discharged  into  the 
uterus.     The  condition  is  rare.      —> 

The  abdominal  ostium  is  closed  in  one  of  two  ways:  1.  Peri- 
tonitic  closure.  Peritonitic  adhesions,  the  result  of  a  localized 
inflammatory  process  aTSout  the  tube-end,  cause  it  to  be  glued  to  any 
organ  with  which  it  may  come  in  contact.  2.  Salpingitic  closure. 
The  fimbriae  become  swollen,  so  as  to  more  nearly  fillthe  tube  end. 
The  circular-muscular  coat,  by  swelling,  narrows  the  lumen  of  the 
outer  end.  Then  the  tube  becomes  lengthened  by  the  swelling,  so 
that  the  muscular  coats  expand  out  over  the  tips  of  the  fimbriae, 
giving  one  the  impression  that  the  fimbriae  have  been  drawn  in. 
Einally,  the  swollen  fimbriae,  pressed  together  by  the  constricting 
muscular  ring,  adhere  so  firmly  that,  even  should  the  inflammation 
subside,  the  lumen  is  not  re-established.  When  both  ends  are 
closed,  we  name  the  variety  of  salpingitis,  according  to  tube  con- 
tents, as — 

1.  Hydrosalpinx. 

2.  Haematosalpinx. 

3.  Pyosalpinx. 

What  is  the  etiology  of  salpingitis  ? 

It  usually  arises  from  an  extension  to  the  tube  of  an  inflammation 
of  the  endometrium,  and  its  etiology  is  that  of  the  endometritis, 

especially — 

1.  Sepsis  during  parturition  or  abortion. 

2.  The  use  of  septic  instruments. 

3.  Gonorrhoea. 


SALPINGITIS.  203 

What  is  the  bacteriology  of  salpingitis  ? 

The  normal  tube  is  free  from  bacteria.  The  most  frequent  inciter 
of  salpingitis  is  the  gonococcus,  after  this  organism  and  about  in  the 
order  of  frequency  in  which  they  are  found  are  the  tubercle  bacillus, 
streptococcus,  staphylococcus,  bacterium  coli  commune,  and  pneumo- 
coccus.  Mixed  infection  is  very  rare.  After  a  time  bacteria  die 
out  in  a  pyosalpinx,  so  that  a  majority  of  such  tubes  examined  have 
been  found  sterile. 

What  are  the  routes   of  infection?    Give  the  usual  path 
followed  by  the  different  organisms. 

1.  By  continuity  of  mucosa  from  the  uterus ;  gonorrhoea;  endo- 
salpingitis ;  pyosalpinx. 

2.  By  way  of  the  abdominal  ostium  ;   tuberculosis. 

3.  Lymphaticroute  ;  streptococcus  and  staphylococcus.  This  "is 
the  common  method  by  which  puerperal  infections  reach  the  tube. 
The  germs  pass  from  the  uterus  to  the  lymphatics  of  the  broad 
ligaments  and  thence  to  the  outer  walls  -of  the  tube.  The  result  is 
a  parietal  or  perisalpingitis. 

4.  Direct  extension,  as  from  adjacent  abscesses  or  hollow  viscera; 
colon  bacillus!    ** 

5.  Blood ;  pyemia ;  tuberculosis. 

What  are  the  characteristics  of  a  hydrosalpinx  ? 

In  a  hydrosalpinx  the  tube  is  distended  with  serum,  its  mucosa 
showing  changes  due  to  pressure,  but  without  evidence  of  severe 
inflammation.  The  softening  of  the  walls  easily  allows  the  dis- 
tention, which  varies  in  position"  according  to  the  traction  of 
peritonitic  adhesions.  Hydrosalpinx  is  occasionally  associated  with 
fibroids  of  the  uterus,  and  is  probably  not  then  of  bacterial  origin. 
It  results  from  peri-  rather  than  endo-salpingitis.  The  theory  that 
it  is  a  transformed  pyosalpinx  has  been  discredited. 

What  are  the  characteristics  of  a  hematosalpinx  ? 

Blood  in  a  tube  may  have  one  of  three  sources  : 

1.  It  may  be  exuded  from  the  tubal  mucous  membrane  as  a  re- 
sult of  inflammation,  the  commonest  form  of  haematosalpinx. 

2.  It  may  occur  as  an  extension  of  a  hsematometra  due  to  atresia 
of  vagina  or  cervix. 

3.  It  most  often  occurs  as  a  result  of  a  tubal  pregnancy.  This  is 
not  classed  as  hiematometra. 


204  ESSENTIALS   OF  GYNECOLOGY. 

The  tube  is  usually  first  hypertrophied,  later  thinned,  and  it  may 
rupture ;  this  accident  is  usually  delayed  by  peritonitic  thickening 
about  the  tube.  The  blood  is  generally  thick  and  tarry.  In  tubal 
pregnancy  it  clots. 

What  are  the  characteristics  of  a  pyosalpinx  ? 

The  tube  is  usually  more  thickened  and  surrounded  by  more  peri- 
tonitic adhesions  than  is  hydrosalpinx. 

The  pus  may  be  slight  in  amount,  or  the  tube  may  be  immensely 
distended  with  very  fetid  pus. 

The  mucous  membrane  of  the  tube  may  be  fairly  well  preserved 
and  the  seat  of  suppurative  inflammation,  or  may  be  replaced  by 
granulation  tissue.  Pus-tubes  may  be  drained  by  rupture  into  hol- 
low viscera  or  intraperitoneal  rupture  may  occur,  resulting  in  pelvic 
abscess  or  general  peritonitis. 

We  are  coming  to  think  of  pyosalpinx  as  gonorrhoeal,  except  in  a 
small  minority  of  cases. 

What  are  the  symptoms  of  salpingitis  ? 

The  patient  usually  suffers  from  a  burning  and  dragging j3ain,  in 
the  region  of  the  affected  tube,  especially  on  standing  and  walking. 
Dysmenorrhea  is  common ;  repeated  attacks  of  peritonitis  are  not 
infrequent.  In  the  case  of  pyosalpinx  septic  symptoms  may  be  pres- 
ent. There  is  tenderness  on  pressure  in~the  lateral  vaginal  fornix, 
and  on  making  a  bimanual  examination  an  elongated  cystic  mass  can 
usually  be  detected  at  the  side  of  or  behind  the  uterus. 

What  are  the  results  of  salpingitis  ? 

A  hydrosalpinx  or  hematosalpinx  occasionally  subsides  so  as  to 
cause  few  symptoms  ;  they  may  become  purulent  and  form  pyo- 
salpinx. 

A  hematosalpinx  may  rupture  into  the  peritoneum  or  into  the 
broad  ligament,  forming  an  hematocele  in  the  former  case,  and  a 
hematoma  in  the  latter. 

A  pyosalpinx  if  unrelieved  by  operation  may  continue  for  years, 
producing  chronic  invalidism,  and  may  rupture  and  cause  septicemia 
or  peritonitis. 

A  salpingitis  rarely  subsides  completely.  Tubes  are  usually  left 
adherent  or  closed  so  as  no  longer  to  act  as  oviducts.    If  not  occluded, 


TUBERCULAR   SALPINGITIS.  205 

their  kinks  and  adhesions  favor  ectopic  gestation.     Recrudescences 
follow  exposure  to  cold,  even  without  any  reinfection. 

What  is  the  treatment  of  salpingitis  ? 

1 .  Prophylactic.  — Cleanliiuess  and  antisepsis  during  the  puerperiuni 
and  in  the  use  of  all  instruments. 

2.  Palliative. — During  the  acute  stage  of  invasion,  rest  in  bed, 
poultices  or  ice  coil,  laxatives,  and,  if  much  pain  is  present,  allow 
orjium. 

When  the  case  becomes  subacute,  i.  e. ,  when  fever  has  entirely 
subsided,  apply  counter-irritation  to  vaginal  fornix  over  the  affected 
tube  or  tubes,  and  employ  tampons  of  boric  acid  and  glycerine  and 
hot-water  vaginal  douches.  So  long  as  pain  and  tenderness  exist, 
rest  in  bed  is  advisable  during  menstruation.  Sexual  intercourse  is 
to  be  avoided. 

3.  Radical. — If  the  distention  and  thickening  of  the  tube  fail  to 
subside  under  the  foregoing  treatment,  remove  the  tube  and  ovary 
of  the  side  affected.  Often  both  sides  are  involved  and  require 
removal.  When  the  tube  is  simply  adherent  and  its  abdominal 
ostium  occluded  and  no  infection  is  present,  a  salpingostomy  can  be 
done,  restoring  the  patency  of  the  tube. 


Tubercular  Salpingitis. 

Give  its  pathology. 

The  infection  may  reach  the  tube  either  through  the  blood,  lymph- 
channels,  endometrium,  or  peritoneum.  It  is  usually  secondary  to 
a  general,  pulmonary,  or  peritoneal  tuberculosis.  Rarely  the  bacilli 
enter  through  the  vagina  and  thus  cause  a  primary  genital  tuber- 
culosis. The  tubes  are  much  more  frequently  affected  than  other 
parts  of  the  genital  tract.  The  tubercular  lesions  are  most  marked 
near  the  abdominal  ostia,  and  both  tubes  are,  as  a  rule,  affected. 

Williams  describes  three  varieties : 

1 .  Miliary  tuberculosis. 

2.  Chronic  diffuse  tuberculosis. 

3.  Chronic  fibroid  tuberculosis. 

The  abdominal  ostia  may  or  may  not  be  occluded.  The  tubes  vary 
in  their  degree  of  distention  with  pus  or  cheesy  material.    The  lesion 


206  ESSENTIALS  OF  GYNAECOLOGY. 

may  be  confined  to  the  mucous  membrane  or  involve  the  entire 
thickness  of  the  tubal  wall. 

What  are  the  predisposing  causes  ? 

The  disease  occurs  from  infancy  to  old  age,  but  is  most  frequent 
between  the  ages  of  twenty  and  forty,  and  seems  predisposed  to  by 
child-bearing  and  the  puerperal  state.  It  has  followed  sexual  inter- 
course when  the  male  genitals  were  tubercular. 

Upon  what  would  you  base  a  diagnosis  of  tubercular  salpin- 
gitis ? 

Absence  of  other  causes  of  pyosalpinx,  as  gonorrhoea  or  infection 
following  labor  or  abortion. 

Evidence  of  other  tubercular  lesions. 

Pallor,  emaciation,  and  cough. 

Physical  examination,  as  a  rule,  reveals  two  large  sausage-shaped 
masses  lying  close  to  the  uterus,  firmly  adherent  and  less  sensitive 
than  is  the  rule  with  pyosalpinx. 

Presence  of  tubercle  bacilli  in  the  uterine  discharge. 

Absence  of  an  initial  acute  stage. 

Chronicity  or  failure  to  respond  to  ordinary  methods  of  treatment. 

What  is  the  treatment  ? 

The  usual  climatic  and  medicinal  treatment  of  tuberculosis.  In 
many  cases  this  is  the  only  treatment.  If,  however,  the  tube  or. 
tube  and  peritoneum  alone  arc  tuberculous,  cosliotomy  is  indicated.' 
The  ovaries  and  tubes  are  removed  and  with  them  the  uterus.  The 
cervix  may  be  left,  as  it  is  rarely  diseased.  The  abdominal  incision 
is  closed  without  drainage. 

Affections  of  the  Ovaries. 

Hemorrhage  into  the  Ovaries. 

Discuss  briefly. 

A  small  amount  of  hemorrhage  into  a  follicle  at  the  time  of 
rupture  is  normal.  Interstitial  hemorrhage  or  apoplexy  of  the  ovary, 
as  it  is  called,  results  from  congestion  due  to  general  circulatory  dis- 
turbances or  local  inflammations.  When  hemorrhage  occurs  there 
is  pain,  and  if  hemorrhage  is  excessive,  which  is  rarely  the  case, 
the  symptoms  may  resemble  those  of  a  ruptured  ectopic  gestation. 


affections  of  the  ovaries.  207 

Ovaritis. 
What  is  the  pathology  ? 

Ovaritis  or  inflammation  of  the  ovary  may  be  acute  or  chronic. 

Tubercular  ovaritis  is  usually  described  separately. 

Acute  ovaritis  may  be  follicular  or  interstitial ;  the  two  are  often 
combined.  In  the  follicular  form,  the  epithelium  of  the  follicles 
degenerates,  the  liquor  folliculi  becomes  purulent,  and  the  ovum  is 
destroyed. 

In  the  interstitial  form,  the  stroma  is  infiltrated  with  serum  and 
leucocytes  and  the  connective  tissue  cells  are  increased ;  abscesses 
often  form  between  the  bundles  of  fibers ;  sometimes  gangrene  occurs. 

Chronic  ovaritis,  often  the  result  of  the  acute,  may  exhibit  3  forms— 

1.  The  atrophic. 

2.  The  hyperplastic. 

3.  The  cystic. 

In  the  atrophic  form  the  ovary  is  small,  hard,  and  nodular ;  the 
tunica  albuginea  is  much  thickened. 

In  the  hyperplastic  form,  the  ovary  is  enlarged,  hard,  and  com- 
paratively smooth  ;  it  usually  prolapses  from  the  increased  weight. 

In  the  cystic  variety,  the  change  is  not  confined  to  the  follicles,  but 
the  stroma  is  involved  as  well. 

The  atrophic  form  may  be  present  in  one  part  of  the  ovary  and  the 
hyperplastic  in  another;  the  tunica  albuginea  is  thickened  and 
prevents  rupture  of  the  cysts.  Ovaries  the  seat  of  ovaritis  are 
often  more  or  less  surrounded  by  peritonitis. 

What  is  the  etiology  of  ovaritis  ? 

It  occasionally  occurs  in  severe  cases  of  the  infectious  diseases  or 
metallic  poisoning,  but  is  most  often  secondary  to  disease  of  the 
tubes  or  peritoneum.  It  is  predisposed  to  by  anything  causing  con- 
gestion of  the  ovary,  such  as  displacement  of  the  uterus  or  ovary  or 
excessive  venery.  A  salpingitis  with  its  own  etiology  is  the  most 
frequent  cause  of  ovaritis.  Among  individual  causes,  the  following 
are  especially  to  be  mentioned  : — 

iSepsis  during  labor,  abortion  or  operations. 

Gonorrhoea. 

Catching  cold  during  menstruation. 


208  ESSENTIALS   OF   GYNECOLOGY. 

What  are  the  symptoms  ? 

The  symptoms  of  acute  ovaritis  are  usually  mingled  with  those 
of  the  accompanying  salpingitis  or  peritonitis.  There  is  generally 
sharp  pain  in  the  ovarian  region  or  regions,  radiating  to  the  back ; 
often  pain  in  micturition  and  defecation,  and  various  reflex  neuroses. 
If  an  abscess  forms,  septic  symptoms  may  be  present. 

In  the  chronic  form  the  symptoms  are  usually  less  marked ;  there 
is  dull  pain  in  the  ovarian  region,  increased  by  walking.  There  is 
dyspareunia  and,  especially  if  the  ovary  is  prolapsed,  painful  defe- 
cation. 

What  are  the  physical  signs  ? 

These  may  be  obscure,  from  the  fact  that  the  ovary  and  tube  are 
bound  together  by  peritonitic  adhesions  into  one  indistinct  mass. 

When  definable,  we  feel,  on  making  a  bimanual  examination,  a 
round  body  at  the  side  of  the  uterus,  but  separated  from  it  by  a 
slight  interval ;  it  is  sensitive  to  pressure,  producing  pain  of  a  sick- 
ening character ;  it  may  or  may  not  be  movable.  When  the  ovary 
is  prolapsed,  this  round,  tender  mass  may  be  felt  in  the  pouch  of 
Douglas. 

From  what  must  you  differentiate  an  inflamed  ovary  ? 

From —  Salpingitis. 

Peritonitic  deposit. 

Exudation  into  the  broad  ligament. 

Fibroid  tumor. 

Faeces  in  the  rectum. 

How  would  you  differentiate  ovaritis  from  salpingitis  ? 

This  is  often  very  difficult,  from  the  fact  that  the  two  conditions 
frequently  coexist.  The  chief  features  in  the  differential  diagnosis 
are  found  in  the  physical  signs,  as  follows  :•— 

Ovaritis  vs.  Salpingitis. 

Lies  farther  from  the  uterus ;      Lies  nearer  the   uterus ;    more 

more  globular  in  shape.  elongated. 

The  ovary  cannot  be  felt  else-      The  ovary  can  often  be  felt  sepa- 

where.  rate  from  the  mass. 

More  sensitive.  Less  sensitive. 


AFFECTIONS   OF  THE   OVARIES.  209 

How  would  you  differentiate  an  ovaritis  from  an  exudation 
in  the  broad  ligament  ? 

Ovaritis  vs.  Exudation  in  Broad  Ligament. 

More  circuru  scribed.  Less  circumscribed. 

Less  closely  related  to  vaginal      More  closely  related  to  vaginal 

vault.  vault. 

Less  fixity  of  the  uterus.  More  fixity  of  the  uterus. 

How  would  you  differentiate  ovaritis  from  a  lateral  uterine 
fibroid  ? 

Ovaritis  vs.  Lateral  Fibroid. 

Sensitive  to  pressure.  Insensitive  to  pressure. 

Less  intimately  connected  with      More  intimately  connected  with 

the  uterus.  the  uterus ;  moves  with  it. 

Density  less.  Density  greater. 

Menorrhagia  less  common.  Menorrhagia  more  common. 

How  would  you  differentiate  ovaritis  from  faeces  in  the 
rectum? 

Ovaritis  vs.                      Faeces. 

More  sensitive.  Less  sensitive. 

Globular.  Elongated  in  shape. 

Does  not  indent  on  pressure.  Indents  on  pressure. 

Found  after  emptying  rectum.  Disappears  on  emptying  rectum. 

What  is  the  treatment  of  ovaritis  ? 

During  the  acute  stage  keep  patient  quiet  in  bed ;  apply  hot 
poultices  to  the  lower  abdomen  ;  keep  bowels  open  and  feces  soft ; 
give  an  anodyne,  if  necessary.  Later,  apply  counter-irritation  by 
means  of  iodine  to  the  vaginal  fornix  over  the  affected  organ,  and 
support  the  ovary  with  a  tampon.  An  excellent  method  is  to  soak 
a  roll  of  gauze  in  a  solution  of  iodoform  1  part,  chloral  1  part,  and 
glycerine  4  parts,  and  place  this  about  the  cervix,  especially  on  the 
affected  side.  After  the  withdrawal  of  this  support,  which  may  be  - 
left  in  twelve  to  twenty -four  hours,  a  hot-water  vaginal  douche  may 
be  used  with  advantage. 

As  a  last  resort,  after  a  faithful  trial  of  the  above  palliative 
measures  for  months  without  avail,  and  if  the  patient  is  a  great 
sufferer,  removal  of  the  offending  organ  is  indicated. 
14 


210  ESSENTIALS   OF   GYNECOLOGY. 

If  abscess  of  the  ovary  is  present,  early  operation  is  indicated. 
An  ovary  the  seat  of  ovaritis  may  be  removed  through  the  vagina. 

Prolapse  of  the  Ovary. 
What  is  the  etiology  and  pathology  ? 

Prolapse  of  the  ovary  may  occur  either  as  a  result  or  cause  of 
disease.  From  the  increase  in  size,  due  to  congestion,  inflammation 
or  small  tumor,  the  ovary  is  apt  to  prolapse. 

In  a  retroversion  or  retroflexion  of  the  uterus,  the  ovaries  also  are 
usually  drawn  backward,  and  from  their  disturbed  circulation  become 
congested  and  diseased.  In  their  descent  they  usually  first  lie  on 
the  retro-ovarian  shelves,  and  may  then  further  descend,  especially 
the  left,  into  the  pouch  of  Douglas. 

What  are  the  symptoms  ? 

They  are  those  of  ovaritis  and  of  ovarian  compression  ;  the  latter 
being  most  marked,  viz.  :  painful  defecation  and  dyspareunia.  (The 
differential  diagnosis  has  been  given  under  ovaritis. ) 

What  is  the  treatment  ? 

(a)  Palliative. — If  due  to  a  displacement  of  the  uterus  and  both 
uterus  and  ovaries  are  movable,  replace  the  uterus  and  maintain  it  in 
position  by  means  of  a  pessary. 

When  the  ovary  alone  is  displaced,  if  movable,  support  it  at  first  with 
a  tampon ;  later  a  soft  rubber  ring  pessary  may  be  worn  about  the  cervix. 

When  the  ovary  is  fixed  by  adhesions,  an  attempt  should  be  made 
to  cause  resolution  of  the  adhesions  by  counter-irritation,  glycerine  or 
boroglyceride  tampons,  hot- water  douches  and  gentle  massage. 

(b)  Radical. — If  the  palliative  measures  fail  and  the  symptoms 
are  severe,  operation  is  indicated,  either  to  remove  the  prolapsed 
ovary,  or,  if  the  uterus  is  displaced  backward,  to  break  up  the  adhe- 
sions and  fasten  the  uterus  forward  by  hysterorrhaphy  or  by  short- 
ening the  round  ligaments. 

Tumors  of  the  Ovary. 

What  are  the  chief  causes  of  enlargement  of  an  ovary? 

{a)  Inflammation.  (d)  Carcinoma. 

{b)  Cysts.  (e)    Fibroma. 

(c)  Papilloma.  (/)  Sarcoma. 

(gr)  Tuberculosis, 


AFFECTIONS   OF  THE   OVARIES*  211 

Discuss  ovarian  sarcoma  and  fibroma. 

Sarcomata  are  chiefly  of  the  round-celled  variety,  but  may  be 
spindle-celled.  They  occur  at  all  ages,  and  not  infrequently  in 
children :  both  ovaries  are  often  affected,  and  they  frequently  give 
rise  to  ascites.     Hemorrhagic  cysts  may  be  formed  in  the  large  ones. 

Fibromata,  as  a  rule,  are  not  so  large  as  sarcomata,  grow  slowly, 
and  do  not  cause  ascites.  The  sarcomata  when  removed  early  arc 
not  very  malignant. 

Discuss  ovarian  papilloma  and  carcinoma. 

Papillomata  occasionally  originate  on  the  surface  of  the  ovary,  but 
more  begin  in  the  wall  of  a  cyst,  whose  wall  they  penetrate  and  then 
spread  over  the  ovary  and  peritoneum.  They  resemble  warts  else- 
where, and  may  be  the  starting-point  of  carcinoma.  Any  ovarian 
cyst  may  have  warty  growths  in  it,  but  they  are  regularly  found  on 
the  walls  of  the  serous  cyst-adenomata,  Rarely,  when  warts  have 
spread  to  the  peritoneum  and  seem  to  be  taking  on  malignant  char- 
acters, the  removal  of  the  ovary  is  followed  by  the  disappearance  of 
the  peritoneal  warts. 

The  ovaries  become  the  seat  of  carcinoma  rarely  primarily,  but 
often  from  extension  or  metastasis.  A  cyst-adenoma  or  ovarian 
papilloma  may  become  carcinomatous. 

What  are  the  varieties  of  ovarian  cyst  ?    Describe  them. 

The  varieties  of  ovarian  cyst  are — 
Corpus  lnteum  cyst. 
Simple  follicular. 
Cyst-adenoma  pseudo-mucinum. 
Cyst-adenoma  serosum. 
Dermoid. 
Corpus  luteum  cysts  rarely  attain  the  size  of  a  child's  head.    They 
contain  fluid  more  or  less  stained  with  blood-pigment,  and  are  lined 
by  a  lutein  membrane. 

The  simple  follicular  cysts  are  often  multiple,  and  originate  in 
distended  Graafian  follicles.  They  are  lined  by  a  layer  of  epithelium 
and  contain  clear  serous  fluid  as  a  rule. 

The  cyst-adenomata  of  the  ovary  form  its  largest  cysts.  They  are 
the  ordinary  multilocular  cysts  and  may  attain  a  very  great  size. 
They  are  adenomata  whose  alveoli  become  distended  with  fluid,  and 
by  breaking  through  of  partition  walls,  cavities  of  several  quarts' 


212  ESSENTIALS   OF   GYNAECOLOGY. 

capacity  are  formed.  Protruding  into  the  larger  loculi  several 
smaller  "secondary"  or  "daughter"  cysts  are  often  seen.  Rarely 
the  daughter  cysts  grow  outward  from  the  walls  of  the  parent  cyst 
and  give  the  tumor  an  outline  like  that  of  a  bunch  of  grapes.  Their 
fluid  is  viscid,  gelatinous,  sometimes  blood-stained,  and  contains 
pseudomucin.     They  originate  in  primordial  ovarian  follicles. 

Cyst-adenoma  pseudo-mucinum  seems  the  most  appropriate 
name.  They  were  formerly  called  the  "proliferating  glandular 
cysts." 

Tlie  cyst-adenomata  serosa  or  proliferating  papillary  cysts.  Any 
ovarian  or  parovarian  cyst  may  have  warty  growths  on  its  inner 
surface,  but  there  is  a  variety  of  cyst  which  invariably  contains 
them,  though  in  variable  numbers,  and  is  thought  to  originate  in 
the  portions  of  the  Wolffian  ducts  which  are  imbedded  in  the  hilum 
of  the  ovary.  The  presence  of  ciliated  epithelium  in  many  of  them 
makes  this  origin  probable.  The  warts  often  grow  so  luxuriantly  as 
to  fill  the  entire  cyst  cavity,  and  even  grow  through  its  walls,  spread- 
ing over  the  surface  of  the  peritoneum.  The  growth  then  behaves 
as  a  papillo-carcinoma. 

The  dermoid  cyst  on  a  part  of  its  interior  is  lined  with  skin. 
Hair  or  teeth  may  grow  from  the  skin  surface  projecting  into  the 
cavity  of  the  cyst.  This  fluid  content  is  made  up  of  the  secretions 
of  the  cutaneous  glands,  chiefly  oil  or  sebaceous  material.  When 
the  latter  preponderates,  they  are  semisolid  in  consistency.  Bone 
cartilage,  nerve  tissue,  and  epithelial-lined  tubular  structures  are 
found  in  the  solid  portions  of  the  growth.  It  is  believed  that  epi- 
blastic,  mesoblastic,  and  hypoblastic  tissues  are  all  represented. 

One  view  as  to  the  origin  of  dermoid  cysts  is  that  they  are  caused 
by  an  abnormal  inclusion  of  the  epiblast — i.  e.,  that  certain  mis- 
placed embryonic  cells  grow  within  the  ovary  and  produce  the  tissue 
to  which  they  were  destined.  The  other  theory  is  that  they  are  to 
be  considered  as  teratomata,  originating  by  a  kind  of  parthenoge- 
netic  development  of  an  ovum  in  the  affected  ovary.  In  favor  of  this 
as  compared  to  the  other  view  is  the  fact  that  they  are  never  found 
congenital.  The  ovary  is  the  only  abdominal  viscus  that  forms 
them.  They  are  most  nearly  paralleled  by  certain  of  the  tumors 
of  the  testis  classed  as  teratomata,  which  contain  a  great  variety 
of  tissues,  including  syncytium. 


AFFECTIONS   OF  THE  OVARIES.  213 

What  is  the  etiology  of  ovarian  cysts  ? 

Concerning  this  little  is  known.  They  occur  most  frequently 
between  the  ages  of  20-50,  but  are  found  in  both  the  young 
and  old. 

Simple  ovaritis  or  injury  of  the  ovary  are  said  by  some  to  predis- 
pose to  the  formation  of  a  cyst. 

What  changes  may  occur  in  an  ovarian  cyst  ? 

The  principal  changes  are  the  following  : — 

It  may  rupture,  usually  from  traumatism. 
Hemorrhage  may  occur  into  it. 
It  may  become  gangrenous  or  may  suppurate. 
The  hemorrhage,  gangrene  and  suppuration  are  usually  the  result 
of  torsion  of  the  pedicle. 

Suppuration  may  also  arise  from  the  introduction  of  sepsis  if  the 
tumor  is  tapped,  as  formerly  practiced. 

What  are  the  symptoms  of  an  ovarian  cyst  ? 

They  are  chiefly  those  of  pressure.  There  may  be  difficulty 
in  urination  and  defecation ;  in  the  later  stages  the  patient  is 
greatly  exhausted  by  the  great  weight,  and  often  suffers  with 
dyspnoea. 

What  are  the  physical  signs  of  an  ovarian  cyst  ? 

These  vary  with  the  location.  When  small  and  in  the  pelvis  we 
get  a  tense  elastic  mass,  usually  fluctuating  and  insensitive  to  pres- 
sure. The  multilocular  variety  may  seem  hard.  The  uterus  is  dis- 
placed by  the  tumor. 

When  the  cyst  has  extended  to  the  abdomen,  we  get  distention  of 
the  abdomen  and  dullness  on  percussion  over  the  tumor.  Fluctua- 
tion can  usually  be  detected. 

What  is  the  relation  of  ovarian  cysts  to  the  uterus  ? 

When  small  the  cyst  prolapses  from  its  own  weight  into  Douglas' 
cul-de-sac ;  hence  the  uterus  will  lie  in  front  of  the  tumor.  When 
the  tumor  is  too  large  to  lie  in  the  pelvis  it  rises  into  the  abdomen, 
the  uterus  then  retroverts  and  lies  under  the  tumor.  Double  ovarian 
cysts,  even  of  large  size,  may  continue  to  lie  behind  the  uterus  and 
displace  it  forward. 


214 


ESSENTIALS   OF   GYNECOLOGY. 


From  what  must  you  differentiate  an  ovarian  cyst  when 
small  and  situated  in  the  pelvis  ? 

From  (a)  Distended  tube. 

(b)  Peritonitic  exudation. 

(c)  Inflammatory  exudation  into  broad  ligament. 

(d)  Extra-uterine  gestation. 

How  would  you  differentiate  a  small  ovarian  cyst  from  a  dis- 
tended tube  ? 

Ovarian  Cyst  vs. 

No  inflammatory  history;  gradual 

development ;  little  if  any  pain. 
More  globular. 
Less  intimately  connected  with 

the  uterus. 
Insensitive  to  pressure. 
Less  fixity. 


Distended  Tube, 
History  of  acute  inflammation ; 

pain  usually  prominent. 
More  elongated. 
More  intimately  connected  with 

the  uterus. 
Sensitive  to  pressure. 
More  fixity. 


How  would  you  differentiate  a  small  ovarian  cyst  from  a  peri- 
tonitic exudation  ? 


Ovarian  Cyst 
No  history  of  acute  inflammation. 
Insensitive. 
More  mobile. 
More  lateral. 

How  would  you  differentiate 
flammatory  exudation 

Ovarian  Cyst 
Absence  of  history  of  inflamma 
tion. 


More  mobile. 

Induration  of  parametrium  want 

ing. 
Insensitive. 
Bulges  less  into  vagina. 


vs.         Peritonitic  Exvdatfon. 
History  of  acute  inflammation. 
Sensitive  to  pressure. 
Fixed. 
Usually  in  pouch  of  Douglas. 

a  small  ovarian  cyst  from  an  in- 
into  the  broad  ligament  ? 

vs.       Inflammatory  Exudation. 

History  of  inflammation  follow- 
ing labor,  abortion,  or  opera- 
tion. If  a  haematoma,  history 
of  sharp  pain,  shock,  perhaps 
symptoms  of  hemorrhage. 

Fixed. 

Induration  present. 

Sensitive  to  pressure. 
Bulges  more  into  vagina. 


AFF'ECTTONS   OF   TIFF   OVARIES. 


21. 


How  would  you  differentiate  an  ovarian  cyst  from  an  extra- 
uterine pregnancy? 

Ovarian  Cyst 
Slow  growth. 
No  symptoms  of  pregnancy. 


Menstruation    usually    not    far 

from  normal. 
More  mobile. 

Uterus  usually  not  enlarged. 
Pain    only   from    pressure ;    no 

acute  attacks. 


vs.       Extra- off: rine  Pregnancy. 

Growth  more  rapid. 

Constitutional  symptoms  of  preg- 
nancy. 

Anienorrhoea  usually  followed  by 
monorrhagia. 

More  fixed. 

Uterus  enlarged. 

Attacks  of  pain  ;  finally  a  severe 
attack,  symptoms  of  shock  and 
hemorrhage. 


From  what  must  you   differentiate   a   large   ovarian    cyst 
occupying  the  abdomen? 
From  (a)  Pregnancy. 

(b)  Ascites. 

( c)  Fibroid  tumor  of  the  uterus. 

(d)  Distended  bladder. 

(e)  Haematometra. 


How  would  you  differentiate  a  large  ovarian  cyst  from  a 
pregnant  uterus  ? 

Ovarian  Cyst  vs.  Pregnant  Uterus. 

More  lateral. 
Menstruation  continues. 
Positive  symptoms  of  pregnancy 

absent. 
Uterus    small,    separate    from 

tumor ;  cervix  not  softened. 
Fluctuating. 

Intermittent  contractions  absent. 
Growth  less  rapid. 


More  central. 

Amenorrhcea  the  rule. 

Positive  symptoms  of  pregnancy 

present. 
Uterus  forms  the  tumor  ;  cervix 

softened. 
Less  fluctuating;  fetal  parts  felt. 
Intermittent  contractions  present. 
Growth  more  rapid. 


216 


ESSENTIALS   OF  GYNECOLOGY. 


How  would  you  differentiate  a  large  ovarian  cyst  from 
ascites  ? 


Ovarian  Cyst 
Patient  on  back  : — 
Swelling  central  or  unilateral. 
Dullness  in  front. 
Tympanitic  on  the  sides. 
Percussion  note  varies  little  on 

turning  patient  from  side  to 

side. 
Circumscribed. 


vs.  Ascites. 

Patient  on  back  : — 
Swelling  bilateral. 
Tympanitic  in  front. 
Dullness  on  the  sides. 
Percussion  note  varies  greatly  in 
turning  from  side  to  side. 

Diffuse. 


How  would  you  differentiate  a  large  ovarian  cyst  from  a 
large  fibroid  tumor  of  the  uterus  ? 

Ovarian  Cyst  vs.  Fibroid. 


Fluctuating. 

Less  intimately  connected  with 

the  uterus. 
Menorrhagia  uncommon. 
Uterus  usually  not  enlarged. 


Firm,  non-fluctuating. 

More  intimately  connected  with 

the  uterus ;  moves  with  it. 
Menorrhagia  common. 
Uterus  usually  enlarged. 


How  would  you  differentiate  a  large  ovarian  cyst  from  a 
distended  bladder  ? 

Ovarian  Cyst  vs.  Distended  Bladder. 

More  lateral.  Central. 

Enlargement  slow.  Enlargement  rapid. 

Remains  after  patient  is  cathe-       Disappears     when     patient    is 
terized.  catheterized. 


How  would  you  differentiate  a  large  ovarian  cyst  from  a 
hsematometra  ? 

Ovarian  Cyst 
Menstrual  flow  appears. 


vs. 


More  lateral ;  separate  from  the 

uterus. 
Pain  only  from  pressure. 

Atresia  absent. 


Hwrnatornetra. 
Menstrual  blood  retained. 
Central ;  tumor  formed  by  the 

distended  uterus. 
Periodical  attacks  of  pain,  due  to 

increase  of  contents. 
Atresia     of   vagina    or    cervix 
present. 


AFFECTIONS   OF  THE  OVARIES.  217 

What  is  the  treatment  of  an  ovarian  cyst  ? 

The  only  treatment  is  removal.  If  large,  through  abdominal 
coeliotomy ;  if  small,  it  can  often  be  easily  removed  through  the 
vagina. 

Parovarian  Cysts. 
Describe  briefly. 

They  are  cysts  developed  in  the  broad  ligament  from  the  parova- 
rium, the  remains  of  the  Wolffian  body.  These  cysts  are  usually 
unilocular  ;  the  contents  colorless,  thin  and  watery,  of  a  specific 
gravity  of  about  1005.  The  cyst  wall  is  usually  thin,  and  fluctu- 
ation very  distinct.  As  the  cyst  grows,  it  opens  up  the  folds  of  the 
broad  ligament,  and  obliterates  the  mesosalpinx.  The  Fallopian 
tube  lies  stretched  out  over  its  upper  surface,  and  the  ovary  will  be 
found  attached  to  the  cyst. 

How  would  you  distinguish  between  an  ovarian  and  par- 
ovarian cyst? 

Ovarian  Cyst  vs.  Parovarian  Cyst 

Has  a  pedicle.  No  pedicle. 

Somewhat  movable.  Deep-seated   in   pelvis   and 

immovable. 
Uterus  in  front  when  small ;   behind       Uterus   pushed  to  opposite 
when  large.  side  when  small ;   forward 

against    symphysis    when 

large. 
What  is  the  treatment  ? 

Removal  by  coeliotomy  is  the  best  treatment.  The  broad  ligament, 
which  is  spread  out  over  the  tumor,  is  incised  near  to  and  parallel  to 
the  tube,  and  the  tumor  is  enucleated  from  its  bed.  The  cavity  in 
the  broad  ligament  is  then  either  closed  so  as  to  leave  no  pockets,  or 
the  edges  of  the  broad  ligament  are  brought  together  above  and 
the  bed  of  the  cyst  is  drained  through  the  vagina.  The  former 
practice  is  usually  preferable  if  there  is  no  bleeding  and  the  opera- 
tion has  been  performed  aseptically. 

What  are  the  chief  points  in  the  technique  of  an  abdominal 
coeliotomy  for  the  removal  of  the  uterine  appendages 
or  a  cyst? 
Have  the  bowels  of  the  patient  thoroughly  emptied  and  let  her 


218  ESSENTIALS   OF  GYNAECOLOGY. 

take  a  thorough  warm  bath.  On  the  evening  before  the  operation, 
place  upon  the  abdomen  a  towel  soaked  in  a  solution  of  soft  soap  to 
be  left  until  the  following  morning.  On  the  day  of  the  operation, 
the  abdomen  and  pubes  are  shaved,  scrubbed  with  soap  and  water, 
washed  with  alcohol,  and  then  with  bichloride  1-1000. 

All  antiseptic  precautions  must  be  observed  in  regard  to  instru- 
ments, hands,  sponges,  etc. 

The  patient  having  been  anaesthetized,  a  final  cleansing  of  the 
abdomen  with  alcohol  and  bichloride  is  performed.  An  incision, 
about  three  inches  long,  is  made  in  the  median  line,  beginning  just 
below  the  umbilicus ;  this  incision  is  deepened  to  the  peritoneum 
and  bleeding  points  are  clamped.  The  peritoneum  is  raised  with 
thumb  forceps,  one  held  by  the  operator,  the  other  by  an  assistant, 
and  the  peritoneum  cut  between  the  forceps ;  the  incision  is  length- 
ened with  the  scissors,  cutting  on  the  finger  to  the  length  of  the 
abdominal  wound.     The  latter  may  be  lengthened,  if  necessary. 

If  the  operation  is  for  the  removal  of  the  appendages,  the  fundus 
of  the  uterus  is  felt  for  as  a  landmark ;  the  ovary  and  tube  of  the 
affected  side  are  brought  into  the  abdominal  wound  and  surrounded 
by  warm  sponges  or  pads.  The  broad  ligament  is  tied  in  section 
beneath  the  appendage  and  the  parts  outside  the  ligature  cut  away, 
leaving  just  enough  to  prevent  the  ligature  from  slipping.  The  first 
ligature  should  be  placed  external  to  the  ovary  including  the  infun- 
dibulo-pelvic  ligament,  which  contains  the  ovarian  artery.  The  liga- 
ture placed  at  the  proximal  end  of  the  tube  should  include  the  anasto- 
motic branch  between  the  uterine  and  ovarian  arteries.  The  ligature 
is  then  cut  short  and  the  stump  dropped  back  into  the  abdominal 
cavity.     The  other  side  is  treated,  if  necessary,  in  the  same  way. 

If  the  operation  is  for  an  ovarian  cyst,  after  opening  the  abdomen 
the  cyst  is  punctured  with  a  trocar,  the  emptied  sac  drawn  out  of 
the  abdominal  wound,  the  adhesions  separated,  if  necessary,  the 
pedicle  tied,  and  the  stump  treated  as  before.  If  pus  has  gotten 
into  the  abdominal  cavity,  the  latter  is  freely  irrigated  with  warm 
sterilized  salt  solution ;  drainage  may  or  may  hot  be  indicated. 

The  abdominal  wound  is  closed  by  one  of  several  methods.  An 
ideal  method  is  that  which  sutures  each  layer  of  the  abdominal  wall 
separately.  A  continuous  catgut  suture  is  used  for  the  peritoneum, 
another  for  the  aponeurosis,  interrupted  catgut  sutures  unite  the 


AFFECTIONS   OF  THE   OVARIES.  219 

subcutaneous  fat,  and  the  skin  is  united  by  any  desired  method  of 
suture.  The  wound  is  then  cleansed,  a  sterile  dressing  is  applied 
and  held  in  place  by  plaster  strips  and  an  abdominal  binder,  and  the 
patient  is  transferred  to  bed.  The  bed  should  be  warmed  with  hot- 
water  bottles,  but  great  care  should  be  taken  that  the  patient  is  not 
burned  by  them. 

What  is  the  after-treatment  of  the  case  ? 

The  patient  receives  no  food  by  the  mouth  for  twelve  to  twenty- 
four  hours,  nutrient  enemata  being  used  if  needed.  After  vomit- 
ing, due  to  the  anaesthetic,  has  subsided,  thirst  is  quenched  by  the 
repeated  administration  of  small  doses  of  hot  water ;  later  conl  or 
carbonated  water  is  given.  The  urine  is  drawn  with  a  catheter. 
As  little  opium  as  possible  is  used.  The  bowels  are  moved  on  the 
third  day  by  enema,  calomel  gr.  iv  (gr.  j  every  half  hour)  or  salines. 
If  tympanites  occurs  at  any  time,  the  bowels  are  moved. 

If  silk  or  silk-worm  gut  sutures  have  been  used  they  should  be 
removed  within  a  week.  The  patient  is  allowed  up  on  the  four- 
teenth to  twenty-first  day. 

Describe  the  vaginal  operation  for  the  removal  of  a  diseased 
appendage  or  an  ovarian  cyst. 
The  same  preliminary  preparations  are  observed  as  for  an  abdom- 
inal cosliotomy.  At  the  time  of  the  operation  the  vulva  and  vagina 
are  thoroughly  disinfected,  the  patient  being  in  the  lithotomy  posi- 
tion and  on  a  Kelly's  pad.  The  perineum  is  retracted  with  a  spec- 
ulum. If  endometritis  is  present  the  uterus  is  first  curetted.  The 
posterior  lip  of  the  cervix  is  then  seized  with  a  volsella  and  drawn 
forward.  The  vagina  is  grasped  with  a  toothed  thumb-forceps  about 
where  it  joins  the  rectum,  and  drawn  downward.  Between  this 
point  and  the  junction  of  vagina  and  cervix  a  cut  is  made  with  scis- 
sors directed  toward  the  uterus ;  first  going  through  the  vagina, 
then  into  the  pouch  of  Douglas.  This  incision  may  be  enlarged 
laterally.  Two  fingers  are  inserted  into  this  opening  and  the  pelvic 
contents  examined.  If  a  diseased  tube  and  ovary  are  found,  a  gauze 
pad  or  sponge,  each  with  a  long  silk  attached,  is  inserted  above  the 
mass  to  be  removed,  to  keep  back  intestines  or  omentum ;  the  ap- 
pendage is  freed,  brought  down  into  the  vagina,  ligated  and  re- 
moved.    The  gauze  pad  or  sponge  is  now  removed  and  the  vaginal 


220  ESSENTIALS   OF   GYNAECOLOGY. 

opening  may  either  be  closed  or  the  pelvic  cavity  may  be  drained 
with  gauze,  according  to  the  indications.  If  an  ovarian  cyst  is 
to  be  removed,  after  opening  the  pouch  of  Douglas  the  cyst  is 
tapped  and  emptied  ;  the  sac  drawn  clown  into  the  vagina,  ligated, 
and  removed. 

What  are  the  advantages  and  disadvantages  of  the  vaginal 
as  compared  with  the  abdominal  operation  ? 

In  the  vaginal  operation  the  shock  is  less  and  the  abdominal 
cicatrix  with  its  tendency  to  hernia  is  avoided. 

The  vaginal  operation  requires  greater  skill  in  operating ;  there 
are  greater  possibilities  of  injuring  gut  in  separating  adhesions,  and 
greater  difficulty  in  repairing  the  damage  ;  it  may  be  hard  to  locate 
and  control  bleeding.  In  some  cases  the  appendages  cannot  be 
removed  by  vagina  until  after  the  removal  of  the  uterus.  Hence 
if  there  is  doubt  as  to  the  diagnosis  and  a  possibility  that  the 
whole  or  a  part  of  an  ovary  or  tube  may  be  allowed  to  remain,  the 
abdominal  route  is  to  be  selected  as  favoring  conservative  surgery. 

What  are  the  indications  for  a  vaginal  operation  ? 

In  those  cases  in  which  the  patient's  condition  will  not  warrant  a 
severe  operation,  a  pelvic  abscess,  pus-tube,  or  ovarian  abscess  may 
be  drained  through  the  vagina.  Later,  after  recovery  from  sepsis, 
an  abdominal  operation  may  be  performed  with  safety. 

A  small  ovarian  cyst  or  prolapsed  ovary  may  be  removed  with 
advantage  through  the  vagina,  as  may  also  a  small  fibroid  in  the 
lower  uterine  segment  through  either  anterior  or  posterior  fornix. 

The  vaginal  route  is  to  be  selected  for  the  drainage  of  any  large 
collection  of  blood,  serum,  or  pus  in  the  pelvis,  which  is  well  walled 
off  by  intestinal  adhesions.  Vaginal  hysterectomy  is  the  operation 
usually  done  for  carcinoma  of  the  uterus. 

What  operations  are  performed  through  the  anterior  fornix  ? 

Small  fibroids  of  the  cervix  or  anterior  uterine  wall  are  removed 
through  the  anterior  fornix.  This  route  is  also  employed  for  short- 
ening the  round  ligaments,  and  by  some  surgeons  for  removal  of 
ovaries  or  tubes. 

How  would  you  prepare  catgut  for  ordinary  ligature  and 
suture? 

The  following  methods  may  be  relied  on  to  kill  all  spores,  such  as 
those  of  tetanus  and  anthrax,  as  well  as  all  germs : 


ECTOPIC   GESTATION.  221 

1.  The  catgut  is  placed  in  small  tubes  half  filled  with  alcohol  and 
hermetically  sealed.  They  are  then  placed  in  a  steam  sterilizer  and 
the  pressure  run  up  to  ten  pounds  of  steam. 

2.  The  catgut  may  be  placed  in  a  heavy  metal  jar  half  filled  with 
alcohol  and  the  lid  tightly  clamped  on.  The  jar  is  then  kept  in 
boiling  water  for  a  half  hour. 

3.  Cumol  is  a  hydrocarbon  which  boils  at  1 79°  C.  The  catgut  is 
first  dried,  then  heated  in  cumol  over  a  sand-bath  to  a  temperature 
near  its  boiling-point.  A  temperature  of  165°  C.  is  maintained  for 
an  hour.  The  cumol  is  poured  off  and  the  catgut  kept  dry  or  trans- 
ferred to  sterile  alcohol.  Absolute  alcohol  should  always  be  used  in 
preference  to  95  per  cent. 

4.  The  Bartlett  Method.  This  gives  a  very  strong  yet  pliable 
gut.  The  gut  is  placed  on  asbestos  in  a  drying  oven  and  kept  at  a 
temperature  not  to  exceed  220°  F.  for  a  half  hour.  This  is  to  rid  it 
of  all  water  and  make  it  penetrable  by  oil.  It  is  then  soaked  for 
twenty-four  hours  in  albolene,  after  which  it  is  heated  in  albolene  in 
an  asbestos-lined  vessel.  The  temperature  is  slowly  run  up  and 
maintained  for  an  hour  or  two  just  under  320°  F.  The  albolene  is 
allowed  to  drip  off  and  the  gut  is  transferred  with  sterile  forceps  to 
a  solution  of  iodine  1  part  to  Columbian  spirits  100  parts,  in  which 
it  is  kept  until  required  for  use. 

How  would  you  prepare  the  chromicized  (McEwen's)  catgut  ? 
Soak  the  gut  for  48  hours  in  the  following  solution  : — 
R .     Acidi  chromici,  J  iij-  g  vss 

Aquae,  q.  s.  ad    Oj 

M.  et  adde 

Glycerini,  Ov. 

Then  store  the  gut  in  carbolized  glycerine  1-5. 
Wipe  with  a  bichloride  towel  before  using. 

Ectopic  Gestation. 

Ectopic  gestation,  as  a  rule,  is  primarily  tubal.  Three  varieties 
are  recognized : 

1.  Tubal  proper  (free  tubal). 

2.  Tubo-uterine  (interstitial)  ;  in  that  portion  of  the  tube  em- 
braced by  the  uterine  wall. 


222  ESSENTIALS   OF  GYNECOLOGY. 

3.  Tubo-ovarian. — Between  the  tube  and  the  ovary,  originally 
tubal. 

Abdominal  pregnancy  is  believed  to  have  been  originally  tubal. 
Ovarian  pregnancy,  apparently  resulting  from  the  impregnation  of 
the  ovum  while  still  in  a  Graafian  follicle,  can  no  longer  be  doubted 
as  a  possibility,  but  the  number  of  well-authenticated  cases  is  still 
small. 

What  is  the  etiology? 

It  has  long  been  recognized  that  tubal  inflammation,  peritoneal 
adhesions,  and  pressure  upon  the  tube  preaispose  to  tubal  pregnancy. 
In  the  case  of  inflammations,  however,  not  until  the  tubal  mucosa 
has  become  practically  normal  is  tubal  pregnancy  likely  to  occur. 
Hindrance  to  the  passage  of  a  fertile  ovum  into  the  uterus  will  not 
of  itself  cause  tubal  implantation  of  the  ovum.  An  hypothesis  has 
been  advanced  by  Webster  that  under  normal  conditions  the  tube 
will  not  undergo  the  decidual  change  necessary  for  pregnancy,  but 
that  the  tubal  mucosa  of  a  few  women  possesses  the  property,  com- 
mon in  many  of  the  lower  animals,  of  responding  to  the  stimulus 
which  the  fertilized  ovum  offers  by  forming  a  decidual  membrane. 
In  such  individuals,  if  the  passage  of  the  ovum  into  the  uterus  is 
interfered  with,  tubal  pregnancy  results.  Doderlein  states  that 
while  there  was  a  history  of  tubal  inflammation  in  90  per  cent,  of 
his  cases,  very  few  of  the  number  were  gonorrhoeal,  and  that  the 
tubal  pregnancy  was  the  first  conception  but  three  times  in  forty-five 
cases.   Others  consider  gonorrhoea  the  commonest  predisposing  cause. 

Discuss  decidua  formation. 

In  extra-uterine  as  in  intra-uterihe  pregnancy  a  decidual  membrane 
forms  in  the  uterus.  It  is  cast  off  at  any  time  from  the  fifth  week 
on,  usually  accompanying  rupture  of  the  tube  or  death  of  the  foetus. 
A  decidual  membrane  also  forms  in  the  tube,  usually  confined  to  a 
small  part  near  the  ovum. 

What  are  the  symptoms  ? 

There  is  usually  a  history  of  a  number  of  years  of  sterility  and 
also  of  pelvic  inflammation. 

1.  Before*rupture*of  the  tube  there  are  symptoms  of  early  preg- 
nancy and  at  times  slight  pains,  usually  thought  to  be  gas  pains,  in 
the  vicinity  of  the  affected  tube. 

2,  The  symptoms  at  the  time  of  rupture  are  those  of  shock, 


ECTOPIC   GESTATION.  223 

internal  hemorrhage,  and  severe  pain  in  the  pelvis.  At  about  this 
time  the  uterine  bleeding  begins  ;  it  is  usually  not  great  in  amount, 
but  continues  for  a  great  number  of*  days.  The  symptoms  of  hem- 
orrhage may  occur  but  once,  or  be  repeated  a  number  of  times. 
Fatal  hemorrhage  may  occur  within  a  very  short  time. 

3.  After  rupture  has  occurred  in  the  stage  of  pelvic  hematoma 
there  is  anaemia  and  often  for  a  time  a  rise  of  temperature.  Blood 
examination  reveals  signs  of  a  secondary  anemia,  and,  in  addition,  a 
moderate  leucocytosis.  There  may  be  pressure  symptoms,  and,  as 
a  rule,  uterine  bleeding  continues. 

4.  If  pregnancy  goes  on  to  term,  labor  pains  appear  and  are  re- 
peated for  a  number  of  days.  The  foetus  then  dies  and  is  converted 
into  a  lithopredion,  to  remain  indefinitely  or  to  be  discharged  piece- 
meal into  hollow  viscera  or  through  sinuses  in  the  abdominal  wall. 
At  times  suppuration  and  sepsis  supervene.  The  abdominal  press- 
ure caused  by  the  spurious  labor  may  cause  rupture  of  the  sac  and 
internal  hemorrhage. 

Why  does  the  tube  rupture  ? 

The  thin  tube  wall  is  incapable  of  much  expansion,  while  the 
ovum  grows  rapidly. 

Further,  the  villi  are  well  formed,  but  the  maternal  portion  of 
the  placenta  formation  is  defective. 

The  syncytium,  too,  is  found  to  have  the  power  to  penetrate  tissues 
and  to  make  its  way  through  the  walls  of  blood  vessels.  By  this 
syncytial  action  the  tube  is  further  weakened,  hemorrhage  is 
favored  from  the  opened-up  tubal  vessels,  and  when  hemorrhage 
has  occurred  about  the  ovum,  the  sudden  increase  of  size  of  the 
mass  causes  the  tube  to  burst.  Many  cases  terminate  without  an 
actual  tube  rupture  with  mole  formation  or  tubal  abortion. 

What  are  the  prospects  of  the  fcetus  in  extra-uterine  preg- 
nancy ? 
The  ovum  may  become  apoplectic  and  foetus  die  within  the  first 
six  weeks.  The  majority  of  the  foetuses  succumb  at  the  time  of 
rupture  or  tubal  abortion.  They  may  die  at  the  time  of  second- 
ary rupture  of  the  gestation  sac.  Probably  not  1  per  cent,  live  to 
term. 


224  ESSENTIALS   OF   GYNAECOLOGY. 

What  are  the  physical  signs  ? 

Before  ruptare^geurs,  the  uterus  is  felt  to  be  enlarged  and  soft- 
ened, and  at  the  side  is  found  a  mass  formed  by  the  distended  tube. 

At  the  time  of  rupture,  if  it  has  occurred  with  hemorrhage  into 
the  peritoneal  cavity,  very  few  physical  signs  may  be  present ;  simply 
an  indistinct  feeling  of  fluid  in  the  pouch  of  Douglas.  Later,  as 
the  blood  coagulates,  a  tumor  is  formed  behind  the  uterus. 

If  the  rupture  has  occurred  into  the  broad  ligament,  a  tumor  is 
formed  at  once  by  the  blood-distended  ligament.  This  tumor  pushes 
the  uterus  forward  and  toward  the  opposite  side.  It  tends  to  bulge 
into  the  vagina,  and  a  finger  introduced  into  the  rectum  detects 
a  narrowing  of  it. 

What  is  the  course  and  result  ? 

Ectopic  gestation  is  nearly  always  tubal.  At  or  shortly  before  the 
third  month,  either  a  rupture  of  the  tubal  wall  may  occur,  with  the 
escape  of  the  foetal  products,  or  the  escape  may  take  place  through 
the  fimbriated  extremity,  constituting  a  tubal  abortion.  When  a 
rupture  of  the  tubal  wall  occurs,  it  may  take  place  ( 1 )  through  a 
portion  covered  b}^  peritoneum,  i.  e..  into  the  peritoneal  cavity,  or 
(2)  through  a  portion  not  covered  by  peritoneum,  /.  e. ,  down  be- 
tween the  folds  of  the  broad  ligament.  The  intraperitoneal  rupture 
may  prove  fatal,  although  often  not  until  several  hemorrhages  have 
occurred.  In  an  extraperitoneal  rupture  the  hemorrhage  is  usually 
limited.  The  foetus  usually  dies  when  it  escapes  from  the  tube. 
When  the  rupture,  however,  is  extraperitoneal,  i  e. ,  between  the 
folds  of  the  broad  ligament,  the  foetus  may  survive,  being  nourished 
by  a  placenta  attached  to  the  floor  and  walls  of  the  pelvis  or  broad 
ligament,  and  go  to  term. 

At  any  time  after  the  middle  of  pregnancy  the  foetal  sac  may 
rupture  and  the  foetus  lie  free  in  the  peritoneal  cavity.  This  con- 
stitutes secondary  rupture  and  explains  the  cases  of  so-called  ab- 
dominal pregnancy.  Primary  rupture  may  be  delayed  in  the  cases 
of  interstitial  pregnancy  until  the  sixteenth  week ;  rupture  is  then 
likely  to  prove  fatal. 

When  the  blood  effusion  is  small  it  may  be  absorved.  Sometimes 
suppuration  occurs, 


ECTOPIC    GESTATION.  225 

From  \vh  it  must  you  differentiate  extra-uterine  pregnancy  ? 

Suppurative  cellulitis. 
Fibroid  tumor. 
Ovarian  cyst. 
Dermoid  cyst. 
Parovarian  cyst. 
Salpingitis. 
Retroversio-flexio. 

What  is  the  treatment  ? 

If  a  diagnosis  is  made  before  rupture  occurs,  the  best  treatment 
consists  in  the  removal  of  the  tube  with  its  contents.  At  the  time 
of  rupture  there  are  two  courses  advocated.  First,  immediate  opera- 
tion, by  opening  the  abdomen  quickly,  reaching  down  into  the  pelvis 
and  determining  from  which  tube  bleeding  occurs ,  and  drawing  the 
tube  up  to  the  wound.  This  traction  temporarily  checks  hemorrhage 
and  the  mesosalpinx  is  ligated  off.  After  this  has  been  done,  blood 
or  clots  are  washed  away  and  the  abdomen  closed.  In  favor  of  this 
course  is  the  uncertainty  as  to  whether  bleeding  will  stop  spon- 
taneously. Second,  treat  the  case  by  rest  and  external  heat  in  the 
hope  that  as  blood-pressure  falls  bleeding  will  cease,  and  that  in  a 
few  hours  the  subnormal  temperature  and  shock  will  be  followed  by 
reaction.  Then  operate  when  the  patient's  condition  will  warrant. 
Advocates  of  this  course  say  a  first  hemorrhage  is  rarely  fatal ;  opera- 
tion with  patient's  pulse  at  150  or  over  usually  is  :  reaction  is  seen  to 
take  place  remarkably  quick  in  some  cases  that  seem  hopeless, 
since  the  blood  is  not  an  entire  loss  to  the  body,  but  its  fluid  portion 
at  least  is  quickly  reabsorbed  once  the  bleeding  has  stopped. 

When  bleeding  has  recently  begun,  if  the  patient's  condition  is 
good,  and  if  proper  facilities  are  at  hand,  operate. 

If  the  condition  has  reached  a  point  where  it  is  reasonably  certain 
that  even  a  short  operation  would  prove  fatal,  if  proper  facilities  for 
a  clean  and  quick  operation  are  not  at  hand  ;  moreover,  if  patient 
must  be  transported  in  a  condition  of  profound  shock  to  a  distant 
hospital,  the  safer  plan  is  the  expectant  one. 

If  the  rupture  has  taken  place  into  the  broad  ligament  and  tj^ 
resulting  hyematoina  is  small,  this  may  be  left  with  the  hope--oT  its 
absorption.     If"  repeated  hemorrhages  occur,  surgical  Interference 
15 


226  ESSENTIALS   OF  GYNAECOLOGY. 

is  indicated.     If  suppuration  take  place,  the  mass  should  he  opened 
from  the  vagina  and  drained. 

If  the  life  of  the  foetus  continues  after  the  rupture,  and  the  case 
is  seen  during  the  early  months,  the  life  of  the  foetus  should  be 
disregarded  in  the  interest  of  the  mother.  The  foetus  and  mem- 
branes should  be  removed  and  the  sac  drained.  If  the  case  is  first 
seen  after  the  viability  of  the  foetus,  an  attempt  should  be  made  to 
save  both  lives. 

Fistulse. 

What  are  the  chief  varieties  met  with  in  gynaecology  ? 

They  may  be  either  urinary  or  fecal. 

Urinary  fistulse  present  the  following  varieties  (see  Fig.  59)  : — 

1.  Urethro-vaginal. 

2.  Vesico-vaginal. 

3.  Yesico-uterine. 

4.  Uretero-vaginal. 

5.  Uretero-uterine. 
The  most  common  is  the  vesico-vaginal. 

The  fecal  fistula  which  especially  concerns  us  is  the  recto-vaginal. 

What  is  the  etiology  of  a  vesico-vaginal  fistula  ? 

The  most  common  cause  is  sloughing  following  long-continued 
pressure,  usually  in  parturition,  but  occasionally  from  a  pessary.  It 
may  be  produced  by  direct  laceration  through  the  septum.  It  is 
predisposed  to  by  a  tedious  labor.  It  may  result  from  cancer  of 
the  cervix. 

What  are  the  symptoms  ? 

The  involuntary  escape  of  urine. 

A  urinous  odor  about  the  person. 

Irritation  and  excoriation  of  the  vulva  and  parts  around. 

How  is  the  diagnosis  made  ? 

If  the  fistula  is  not  evident  on  exposing  the  parts  with  a  Sims' 
speculum,  the  patient  being  in  Sims'  position,  the  bladder  may  be 
distended  with  some  colored  antiseptic  fluid,  like  creolin  solution, 
and  by  the  exit  of  the  latter  the  fistula  may  be  detected,  and  then 
verified  by  a  probe, 


FTSTUL^E. 


227 


What  is  the  treatment  ? 

The  treatment  usually  pursued  in  this  country  is  the  operation  of 
Sims,  which  is  performed  as  follows:  The  patient  is  anaesthetized, 
an  antiseptic  vaginal  douche  given,  and  all  antiseptic  precautions 
observed  during  the  operation.  She  is  placed  in  Sims'  position 
and  Sims'  speculum  introduced.  The  edges  of  the  fistula  are  pared 
with  the  knife  or  scissors,  the  mucous  membrane  not  being  included 
in  the  incision.  Silkworm-gut  or  silver-wire  sutures  are  then  intro- 
duced, about  one-fifth  to  one-fourth  inch  apart,  not  penetrating  the 
mucous  membrane.  The  parts  are  brought  into  apposition  by  tying 
or  twisting  the  sutures,  and  then  a  self-retaining  catheter  is  intro- 
duced.    The  sutures  are  left  for  eight  days.     The  operation  for 


Fig.  59. 


To   REPRESENT   THE   CHIEF    VARIETIES   OF   URINARY    FlSTlTLA— URETHku-VAGINaI  , 

Vesicovaginal  and  Vesicouterine—  Those  with  the  ureters  are  not,  seen! 
The  seat  of  a  recto-vaginal  fistula  is  indicated  (De  Sinety). 

a  urethro-vaginal  fistula  is  similar  to  the  above. 

When  the  fistula  is  a  large  one  and  the  traction  necessary  to 
bring  the  vaginal  edges  together  would  be  too  great,  other  methods 
must  be  employed.  The  vaginal  wall  may  be  separated  from  the 
bladder  wall  and  the  two  sutured  separately.  The  vaginal  sutures 
may  be  so  placed  as  to  make  the  suture  line  transverse,  or  lateral 
incisions  may  be  made  in  the  vaginal  wall  to  relieve  tension,  much  as 
is  done  in  the  operation  of  uranoplasty. 


228  ESSENTIALS   OE  GYNAECOLOGY. 

What  are  the  chief  steps  in  the  operation  for  the  cure  of  a 
vesico-uterine  fistula  ? 

Emmet  regards  the  condition  as  due  to  a  laceration  of  the  cervix 
extending  into  the  bladder,  the  laceration  healing  only  below.  The 
operation  is  based  on  this  idea,  viz. :  The  cervix  is  split  up  to  the 
fistula ;  the  edges  of  the  latter  are  denuded,  and  the  whole  brought 
together  in  a  manner  similar  to  a  trachelorrhaphy,  especial  care  being 
taken  with  the  upper  sutures. 

Recto- vaginal  Fistula. 

What  is  the  etiology  ? 

This,  like  the  vesico-vaginal  fistula,  is  usually  due  to  sloughing 
caused  by  long-continued  pressure  in  parturition,  or  may  be  produced 
by  laceration  through  the  septum,  either  by  the  unaided  efforts  of 
nature  or  by  instrumental  delivery.  Cancer  or  syphilis  may,  of 
course,  cause  fistula,  but  this  will  not  concern  us  here. 

What  is  the  treatment  ? 

It  is  similar  to  Sims'  operation  for  vesico-vaginal  fistula.  The 
edges  are  denuded  and  brought  together  by  silkworm  gut  or  silver 
wire,  the  rectal  mucous  membrane  being  uninjured.  If  the  fistula 
is  near  the  vulva,  it  is  usually  best  to  divide  the  sphincter  ani  and 
perineum  up  to  the  fistula,  to  dissect  this  out,  and  then  close  the 
parts  as  in  a  laceration  of  the  perineum  through  the  sphincter  ani. 


INDEX 


Alcohol,  67 

Alexander's  operation,  133 
Allen's  pump,  63 
Amenorrhcea,  105 
Anterior  colporrhaphy,  152 
Applicator,  uterine,  60 
Atresia  of  cervix,  116 

of  vagina,  1 15 
Atrophy  of  uterus,  173 

Bacteria  of  endometritis,  161 
of  salpingitis,  203 
of  vagina,  89 

Barnes'  bags,  63 

Bartlett  method  of  preparing  cat- 
gut, 221 

Bimanual  examination,  46 

Bladder,  36 

Bulbi  vestibuli,  20 

Cancrum  oris,  74 
Cantharides,  tincture  of,  66 
Carcinoma,  ovarian,  211 

uteri,  193 
Catgut,  preparation  of,  220 
Cathartics,  66 
Cellulitis,  pelvic,  97 
Cervical  erosions,  164 
Chancre,  83 

Chorio-epithelioma,  200 
Cilia;,  32 
Clitoris,  18 
Coccygodynia,  86 
Colon,  pelvic,  39 
Colporrhaphy,  anterior,  152 
Condylomata,  pointed,  82 

syphilitic,  83 
Corpus  luteum  cyst,  211 


Cragin's  operation,  151 

Curettage,  169 

Curette,  64 

Cystoscope,  Kelly,  49,  54,  55 

JSTitze,  55 

Otis,  55 
Cysts  of  ovary,  211 

Decidua  formation,  222 
Development  of  the  pelvic  organs, 

43 
Dilators,  60 
elastic,  63 
graduated,  hard,  61 
Displacements  of  uterus,  122 
anteflexion,  122 
ante  version,  122 
retroversion   and  retroflexion, 
125 
Drugs,  action    on    pelvic    organs, 

66-68 
Diihrssen   operation   for  prolapse, 

141 
Dysmenorrhcea,  108 

Ectopic  gestation,  221 
Eczema  of  vulva,  80 
Emmenagogues,  66-68 
Emmet's  operation,  144 

compared  with  Hegar's,  145 
Endometritis,  161 

acute,  161 

chronic,  163 

villous,  167 
Ergot,  66 

Erosions,  cervical,  164 
Erythema  of  vulva,  79 

229 


230 


INDEX. 


Fallopian  tubes,  31 
Fibroid  tumors  of  uterus,  174 
ovarian,  211 

choice  of  operation,  184 
Fistula,  rectovaginal,  228 
Fistulae,  226 
Follicular  cysts,  211 
Fornix,        anterior,        operations 

through,  220 
Fossa  navicularis,  20 
Fourchette,  20 
Fungosities,  uterine,  167 

Gilliam  operation  through  Pfan- 

nenstiel    incision  for  shortening 

round  ligaments,  136 
Gonococcus,  69 

antiserum,  71 

examination  of  discharge  for,  71 

vaccine,  71 
Gonorrhoea,  69 
Gynecologic  positions,  44 

Hematocele      and      haematonia, 
pelvic,  100 

pudendal,  77 
Haemorrhage  from  vulva,  79 
Hegar  operation,  143 

compared  with  Emmet's,  145 
Hernia,  pudendal,  77 
Herpes  of  vulva,  81 
Hydrastis  canadensis,  66 
Hymen,  21 

Hyperaesthesia  of  vulva,  85 
Hypertrophy  of  cervix,  154 
Hysterectomy,  183 

abdominal    and  vaginal,  relative 
merits,  198 

and  oophorectomy   for   fibroids, 
184 

vaginal,  182,  197 
Hysterorrhaphy,  134 

Kelly's,  135 

Instruments,  49 
Inversion  of  uterus,  185 
Iron,  66 

Irritable  urethral  caruncle,  87 
Ischiorectal  fossa,  42 


Kelly's  hysterorrhaphy,  135 

Kraurosis  vulvae,  85 

Labia  majora,  17 

minora,  18 
Laceration  of  cervix,  156 

of  perineum,  141 

Mackenrodt  colpotomy  incision, 

153 
Malformations  of  uterus,  117 
of  vagina,  115 
atresia  of,  115 
stenosis  of,  117 
of  vulva,  89 
Martin  suture,  143,  144 
Menopause,  105 

bleeding  after,  194,  195 
Menstruation,  104 
disorders  of,  105 
amenorrhoea,  105 
dysmenorrhoea,  108 
congestive,  110 
membranous,  111 
neuralgic,  111 
obstructive,  109 
ovarian,  111 
menorrhagia       and       metror- 
rhagia, 107 
vicarious,  107 
Mesosalpinx,  30 
Metritis,  170 
acute,  170 
chronic,  171 
Mons  veneris,  17 
Myomectomy,  182 

New  growths  of  vulva,  81 
Noble's  operation,  150 
Noma,  74 

One-child  sterility,  114 
Oophorectomy    and    hysterectomy 

for  fibroids,  184 
Ovarian  extracts,  67 
Ovaries,  33 

affections  of,  206 

cysts,  211 

enlargement  of,  210 

haemorrhage  into,  206 


INDEX. 


231 


Ovaries,  prolapse  of,  210 

tumors  of,  210 
Ovaritis,  207 

Papillomata,  ovarian,  211 
simple,  82 

Parovarian  cysts,  217 

Parovarium,  35 

Parsley,  66 

Pelvic  colon,  39 
hour,  40 
organs,  drugs  acting  on,  66-68 

Pennyroyal,  66 

Perineal  body,  41 

Perineum,  muscles  of,  42 

Peritoneum,  pelvic,  93 

Peritonitis,  pelvic,  94 

Pessaries,  130 
stem,  64 

Physical    examination    of     pelvic 
organs,  43 

Polypi,  190 

Positions,  gynecologic,  44 

Prepuce,  adherent,  82 

Probe,  uterine,  60 

Proctoscope,  Tuttle,  49 

Prolapse  of  urethral  mucous  mem- 
brane, 88 

Prolapsus  uteri,  137 

pubo-coccygeus  muscles  and,  139 

Pruritus  vulvae,  84 

Pubic  segment  of  pelvic  floor,  138 

Pubo-coccygeus  muscles   and   pro- 
lapse, 139 

Pudendal  hematocele,  77 
hernia,  77 


Quinine,  66 


Rectal  examination,  48 

instrumental  methods,  49 
Rectum,  38 

Round  ligaments,  Gilliam   opera- 
tion   through    Pfannenstiel 
incision  for  shortening,  136 
intra-abdominal  shortening  of, 
136 
Rue,  66 


Sacral  segment  of  pelvic  floor,  138 
Saenger-Tait  operation,  146 
Salpingitis,  201 

tubercular,  205 
Sarcoma  of  uterus,  199 

ovarian,  211 
Savine,  66 

Skin  diseases  of  vulva,  79 
Sound,  uterine,  56 
Speculum,  49 

Brewer's,  53 

Fergusson's,  52 

Kelly's,  49,  54,  55 

Simons',  51 

Sims',  49 
Sphincter,  torn,  operations  for,  150 
Stem  pessaries,  64 
Stenosis  of  cervix,  155 

of  vagina,  117 
Sterility,  113 

Stoltz's  anterior  colporrhaphy,  152 
Syphilis,  83 
Syphilitic  chancre,  83 

condylomata,  83 

Tents,  60 

Tertiary  syphilis,  83 
Theca  folliculi,  34 
Thyroid  extract,  67 
Tincture  of  cantharides,  66 
Trachelorrhaphy,  160 

Urinary  tract,  35 
Uterine  applicators,  60 

fungosities,  167 

ligaments,  action  of,  31 
Uterus,  24 

displacements  of,  122 

malformations  of,  117 

mucous  membrane  of,  25 
changes  of,  26 

Vagina,  21 
atresia  of,  115 
bacteria  of,  89 
diseases  of,  89 
malformations  of,  115 
pathogenic  germs  in,  22 
secretions  of,  22 
stenosis  of,  117 


232 


INDEX. 


Vaginal  examination,  45 
outlet,  relaxations  of,  141 
reaction,  changes  in,  22 

Vaginismus,  86 

Vaginitis,  croupous,  93 
gonorrhoea^  91 
simple  catarrhal,  90 
ulcerative,  92 

Vestibule,  20 

Viburnum,  67 

Vicarious  menstruation,  107 

Volsella,  55 

Vulva,  chancre  of,  83 
malformations  of,  89 


Vulva,  syphilis  of,  tertiary,  83 
Vulvitis,  68 

acute  simple  catarrhal,  68 

chronic  catarrhal,  69 

croupous,  74 

follicular,  74 

gangrenous,  74 

gonorrhoeal,  69 

phlegmonous,  72 
Vulvovaginal  gland,  21 
cyst  and  abscess  of,  75 

Warren's  operation  when  sphinc- 
ter is  torn,  150 


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Boston's 
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Clinical  Diagnosis.  By  L.  Napoleon  Boston,  M.  D., 
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By  H.  D.  Rolleston,  M.  D.  (Cantab.),  F.  R.  C.  P.,  Physician  to 
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INCLUDING    GALL-BLADDER    AND    BILE-DUCTS 

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Prof.  Dr.  H.  Sahli,  of  Bern.  Edited,  with  additions,  by  Fran- 
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Friedenwald  and  Ruhr  ah 
on  Diet 


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MATERIA    MEDIC  A. 


Stevens' 
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A  Text=Book  of  Modern  Materia  Medica  and  Thera- 
peutics. By  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on  Phy- 
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Camac's 
Epoch-Making    Contributions 

Epoch=making  Contributions  to  Medicine  and  Surgery. 

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IO 


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AMERICAN    EDITION 


NOTHNAGEL'S   PRACTICE 

UNDER    THE    EDITORIAL    SUPERVISION    OF 


ALFRED    STENGEL,    M.D. 

Professor  of  Clinical  Medicine  in  the  University  of   Pennsylvania  ;  Visiting 
Physician  to  the  Pennsylvania  Hospital. 


BEST  IN 
EXISTENCE 


FOR    THE 
PRACTITIONER 


It  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal 
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the  best  Practice  of  Medicine  in  existence.  So 
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represents  the  very  latest  views  of  the  leading 
American  and  English  specialists  in  the  various  de- 
partments of  Internal  Medicine.  Moreover,  as 
each  volume  has  been  revised  to  the  date  of  its 
publication  by  the  eminent  editor,  the  objection 
that  has  heretofore  existed  to  treatises  published  in  a  number  of  volumes  has 
been  obviated,  since  the  subscriber  receives  the  completed  work  while  the  earlier 
volumes  are  still  fresh.  The  American  publication  of  the  entire  work  is  under 
the  editorial  supervision  of  Dr.  ALFRED  STENGEL,  who  has  selected  the  sub- 
jects for  the  American  Edition,  and  has  chosen  the 
editors  of  the  different  volumes. 

The  usual  method  of  publishers  when  issuing  a 
publication  of  this  kind  has  been  to  require  physi- 
cians to  take  the  entire  work.  This  seems  to  us  in 
many  cases  to  be  undesirable.  Therefore,  in  pur- 
chasing this  Practice  physicians  are  given  the  opportunity  of  subscribing  for 
it  in  entirety  ;  but  any  single  volume  or  any  number  of  volumes,  each  complete 
in  itself,  may  be  obtained  by  those  who  do  not  desire  the  complete  series.  This 
latter  method  offers  to  the  purchaser  many  advantages  which  will  be  appreciated 
by  those  who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

Subscription. 

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ii 


AMERICAN    EDITION 


Nothnagel's  Practice 

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Typhoid  and  Typhus  Fevers 

By  Dr  H.  Curschmann,  of  Leipsic.  The  entire  volume  edited  with 
additions,  by  Wm.  Osler,  M.D.,  F.  R.  C.  P.,  Regius  Professor  of  Medi- 
cine, Oxford  University,  Oxford,  England.  Octavo,  646  pages,  illus- 
trated. 

Smallpox  (including  Vaccination),  Varicella,  Cholera, 
Erysipelas,  Pertussis,  and  Hay  Fever 

By  Dr.  H.  Immermann,  of  Basle ;  Dr.  Th.  von  Jurgensen,  of 
Tubincren  •  Dr.  C.  Lieberm lister,  of  Tubingen  ;  Dr.  H.  Lenhartz, 
of  Hamburg;  and  Dr.  G.  Sticker,  of  Giessen  The  entire  volume 
edited,  with  additions,  by  Sir  J.  W.  Moore,  M.  D  F.  R  C.  PI. 
Professor  of  Praciice,  Royal  College  of  Surgeons,  Ireland.  Octavo,  682 
pages,  illustrated. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  William  P.  Northrup,  M.  I).,  of  New  York,  and  Dr.  Th.  von 
Jurgensen,  of  Tubingen.  The  entire  volume  edited,  with  additions,  by 
William  P.  Northrup,  M.  D.,  Professor  of  Pediatrics,  University  and 
Bellevue  Hospital  Medical  College,  N.  Y.       Octavo,  672  pages,  illus. 

Bronchi  and  Pleura;  Inflammations  of  the  Lungs 

By  Dr.  F.  A.  Hoffmann,  of  Leipsic  ;  Dr.  0.  Rosenbach,  of  Berlin ; 
and  Dr  F.  Aufrecht,  of  Magdeburg.  The  entire  volume  edited,  with 
additions,  by  John  H.  Musser,  M.  D..  Professor  of  Clinical  Medicine, 
University  of  Pennsylvania.     Octavo,  1029  pages,  illustrated. 

Diseases  of  the  Pancreas,  Suprarenals,  and  Liver 

By  Dr.  Oser,  of  Vienna  ;  Dr.  E.  Neusser,  of  Vienna  ;  and  Drs. 
H  Quincke  and  G.  Hoppe-Seyler,  of  Kiel.  The  entire  volume  edited, 
with  additions,  by  Reginald  H.  Fitz,  A.  M.,  M.  D.,  Hersey  Professor  of 
the  Theory  and  Practice  of  Physic,  Harvard  University;  and  Frederick 
A.  Packard,  M.  D.,  Late  Physician  to  the  Pennsylvania  Hospital.  Octavo, 
918  pages,  illustrated. 

Diseases  of  the  Stomach 

By  Dr.  F.  Riegel,  of  Giessen.  Edited,  with  additions,  by  Charles 
G.  Stockton,  M.  D.,  Professor  of  Medicine,  University  of  Buffalo. 
Octavo  of  835  pages,  illustrated.  Second 

Diseases  of  the  Intestines  and  Peritoneum  Edition 

By  Dr.  Hermann  Nothnagel,  of  Vienna.  The  entire  volume  edited, 
with  additions,  by  H.  D.  Rolleston,  M.  D.  (Cantab.),  F.  R.  C.  P., 
Physician  to  St.  George's  Hospital,  London.  Octavo  of  1 100  pages, 
illustrated. 


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Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  Dr.  G.  Cornet,  of  Berlin.  Edited,  with  additions,  by  Walter 
B.  James,  M.  D.,  Professor  of  Practice,  Columbia  University,  New  York, 
Octavo  of  806  pages. 

Diseases  Of   Blood   {Anemia,  Chlorosis,  Leukemia,  Pseudoleukemia) 

By  Dr.  P.  Ehrlich,  of  Frankfort-on-the-Main  ;  Dr.  A.  Lazarus,  of 
Charlottenburg  ;  Dr.  K.  VON  NOORDEN,  of  Frankfort-on-the-Main  ;  and 
Dr.  Felix  Pinkus,  of  Berlin.  The  entire  volume  edited,  with  additions, 
by  Alfred  Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University 
of  Pennsylvania.     Octavo  of  714  pages,  illustrated. 

Malaria,  Influenza,  and  Dengue 

P-y  Dr.  J.  Mannaberg,  of  Vienna,  and  Dr.  O.  Leichtenstern,  of 
Cologne.  The  entire  volume  edited,  with  additions,  by  Ronald  Ross, 
F.  R.  C.  S.  (Eng.),  F.  R.  S.,  University  of  Liverpool;  J.  W.  W. 
Stephens,  M.  D.,  D.  P.  H.,  University  of  Liverpool  ;  and  Albert 
S.  Grunbaum,  F.  R.  C.  P.,  University  of  Liverpool.  Octavo  of  769 
pages,  illustrated. 

Kidneys,  Spleen,  and  Hemorrhagic  Diatheses 

By  Dr.  Ff.  Senator,  of  Berlin,  and  Dr.  M.  Litten,  of  Berlin.  The 
entire  volume  edited,  with  additions,  by  James  B.  Herrick,  M.  D.,  Pro- 
fessor of  the  Practice  of  Medicine,  Rush  Medical  College.  Octavo  of 
815  pages,  illustrated. 

Diseases  of  the  Heart 

By  Prof.  Dr.  Th.  von  Jurgensen,  of  Tubingen  ;  Prof.  Dr.  L, 
Krehl,  of  Greifswald ;  and  Prof.  Dr.  L.  von  Schrotter,  of 
Vienna.  The  entire  volume  edited,  with  additions,  by  George  Dock* 
M.  D.,  Professor  of  Theory  and  Practice  of  Medicine  and  Clinical 
Medicine,  Tulane  University  of  Louisiana.  Octavo  of  848  pages,  fully 
illustrated. 


SOME  PRESS  OPINIONS 


London  Lancet  {Typhoid volume) 

"We  welcome  the  translation  into  English  of  this  excellent  practice  of  medicine.  The 
first  volume  contains  a  vast  amount  of  useful  information,  and  the  forthcoming  volumes  are 
awaited  with  interest." 

Journal  American  Medical  Association  (  Tuberculosis  volume) 

"  We  know  of  no  single  treatise  covering  the  subject  so  thoroughly  in  all  its  aspects  as. 
this  great  German  work.  .  .  .  It  is  one  of  the  most  exhaustive,  practical,  and  satisfactory- 
works  on  the  subject  of  tuberculosis." 

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MATERIA    MEDIC  A. 


Sollmann's  Pharmacology 

Including  Therapeutics,  Materia  Medica,  Pharmacy, 
Prescription -writing,  Toxicology,  etc. 


A  Text=Book  of  Pharmacology.  By  Torald  Sollmann, 
M.  D.,  Professor  of  Pharmacology  and  Materia  Medica,  Western 
Reserve  University,  Cleveland,  Ohio.  Octavo  of  1070  pages,  fully 
illustrated.     Cloth,  $4.00  net;  Half  Morocco,  $5.50  net. 

THE    NEW    (2d)    EDITION 

This  work  has  been  entirely  reset  to  conform  with  the  new  (1905)  Phar- 
macopeia. The  author  bases  the  study  of  therapeutics  on  a  systematic  knowl- 
edge of  the  nature  and  properties  of  drugs,  and  thus  brings  out  forcibly  the 
intimate  relation  between  pharmacology  and  practical  medicine. 

J.  F.  Fothering'ham,  M.  D., 

Professor  of  Therapeutics  and  Theory  and  Practice  of  Prescribing,  Trinity  Medica? 

College,  Toronto 

"  The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scientific  a 
manner  by  any  other  text  I  have  read  on  the  subjects  embraced." 

Butler's  Materia  Medica 

Therapeutics,  and  Pharmacology 

A  Text=Book  of  Materia  Medica,  Therapeutics,  and 
Pharmacology.  By  George  F.  Butler,  Ph.  G.,  M.  D.,  Pro- 
fessor and  Head  of  the  Department  of  Therapeutics  and  Pro- 
fessor of  Preventive  and  Clinical  Medicine,  Chicago  College  of 
Medicine  and  Surgery,  Valparaiso  University.  Octavo,  702 
pages,  illustrated.     Cloth,  $4.00  net;  Half  Morocco,  $5.50  net. 

THE    NEW    (6th)    EDITION 

In  this  new  edition  the  chapters  on  Organo-therapy,  Serum-therapy,  and 
cognate  subjects  have  been  enlarged  and  carefully  revised.  An  important 
chapter  is  the  one  devoted  to  the  newer  theories  of  electrolytic  dissociation  and 
its  relation  to  the  topic  of  pharmacotherapy. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the 
completeness  of  the  text." 


14  SAUNDERS'    BOOKS    ON 


Lusk  on  Nutrition 

The  Elements  of  the  Science  of  Nutrition.  By  Graham 
Lusk,  Ph.  D.,  Professor  of  Physiology  at  Cornell  Medical  School. 
Octavo  volume  of  325  pages.     Cloth,  $2.50  net. 

THE    FOUNDATIONS    OF    DIETARY    MANAGEMENT 

Dr.  Lusk  presents  the  scientific  foundations  upon  which  rests  our  knowl- 
edge of  nutrition  and  metabolism,  both  in  health  and  in  disease.  There  are 
special  chapters  on  the  metabolism  of  diabetes  and  fever,  and  on  purin  meta- 
bolism; and  the  nutritive  requirements  during  pregnancy,  lactation,  growth, 
etc.,  are  also  clearly  discussed. 

Lewellys  F.  Barker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University. 
"  I  shall  recommend  it  highly  to  my  students.     It  is  a  comfort  to  have  such  a  discus- 
sion of  the  subject  in  English." 


Eichhorst's  Practice 

Practice  of  Medicine.  By  Dr.  H.  Eichhorst,  University  of 
Zurich.  Edited  by  A.  A.  Eshner,  M.  D.  Two  octavos  of  600  pages 
each,  with  150  illustrations.      Per  set  :   Cloth,  $6.00  net. 

Hatcher  and  Sollmann's  Materia  Medica 

A  Text-Book  of  Materia  Medica  :  including  Laboratory  Exer- 
cises in  the  Histologic  and  Chemic  Examination  of  Drugs.  By  Robert 
A.  Hatcher,  Ph.  G.,  M.  D.;  and  Torald  Sollmann,  M.  D.  i2mo 
of  411  pages.     Flexible  leather,  $2  00  net. 

Mathews*  How  to  Succeed  in  Practice 

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99.     i2mo  of  215  pages,  illustrated.     Cloth,  $1,50  net. 

Bridge  on  Tuberculosis 

Tuberculosis.  By  Norman  Bridge,  A.  M.,  M.  D.  i2mo  of  302 
pages,  illustrated.     Cloth,  $1.50  net. 


MATERIA    MEDIC  A   AND    THERAPEUTICS  15 

The  American  Pocket  Medical  Dictionary. 

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A.  Newman  Dorland,  M.  D..  Assistant  Obstetrician  to  the  Hospital  of 
the  University  of  Pennsylvania.  Containing  the  pronunciation  and  defi- 
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peutics and  Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D., 
and  Eugene  W.  Caldwell,  B.  S.  Octavo  of  625  pages,  with  200 
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Cohen   and   Eshner's    Diagnosis.     Second  Revised  Edition 

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.    Phila.  ;  and  A.  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Phila- 
delphia  Polyclinic.      Post-octavo,   382    pages;    55    illustrations.     Cloth, 
fil.oo  net.      In  Saunders'    Question- Compend  Series. 

Morris*  Materia  Medica  and  Therapeutics, 

Recently  Issued — New  (7th)  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescrip- 
tion-Writing,. Bv  Hexry  Morris,  M.  D.  Revised  by  W.  A.  Bas- 
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University.     1 2mo,  300  pages.      Cloth,  $1. 00  net.    Saunders'  Compends. 

Williams'  Practice  of  Medicine 

Essentials  of  the  Practice  of  Medicine.  By  W.  R.  Williams, 
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peutics, and  Walter  A.  Wells,  M.  D.,  Demonstraior  of  Laryngology, 
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intendent of  the  Training  School  for  Nurses  at  the  Carney  Hospital, 
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Grafstrom's  Mechano-Therapy        Second  Revised  Edition 

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1 6  SAUNDERS'    BOOKS    ON   PRACTICE,   Etc. 


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A.  A.  Eshner,  M.  D.  182  colored  figures  on  68  plates,  64  text-cuts, 
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Lockwood's  Practice  of  Medicine    Revi5ef3dE„EiS 

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wood,  M.  D.,  Attending  Physician  to  the  Bellevue  Hospital,  New  York 
City.     Octavo,  847  pages,  illustrated.     Cloth,  $4.00  net. 

Gould  and   Pyle's   Curiosities   of  Medicine 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
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gravings, and  12  full-page  plates.     Cloth,  $3.00  net. 

Jelliffe's   Pharmacognosy 

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Stevens'   Practice   of  Medicine  New  (8th)  Edition 

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Todd's  Clinical  Diagnosis  Recently  issued 

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Medicine,  Denver.  i2mo  of  319  pages,  illustrated.  Flexible  leather, 
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tory methods  of  clinical  usefulness  which  have  been  tried  by  the  test  of  experience." 
— Boston  Medical  and  Surgical  Journal. 


